LUMBAR STRAIN: Back to the Basics 1 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] I. Epidemiology Low back pain (LBP) is the second most common symptom that causes patients to seek medical attention in the outpatient setting. Approximately 70% of adults have an episode of LBP as a result of work or play. Hundreds of millions of dollars are spent in the diagnosis and treatment of this array of conditions. II. Anatomy A. Bones 1. Vertebral body 2. Vertebral arch- 2 pedicles, 2 lamina, 2 pars interarticularis. 3. Cartilaginous endplateshyaline cartilage separates annulus and nucleus from vertebral body. B. Soft tissue 1. Disc- made up of peripheral annulus fibrosus (fibrous) and the central nucleus pulposus (gelatinous). A "slipped disc" really represents a leakage of the NP into the foramen. A subsequent inflammatory reaction may irritate the nerve root. 2. Ligaments- the anterior and posterior longitudinal ligaments run the length of the vertebral bodies and resist flexion and extension. The interspinous ligament attaches two adjacent spinous processes. The supraspinous ligament attaches all spinous processes. LBP 12/20/05 LUMBAR STRAIN: Back to the Basics 2 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] 3. Muscles- the large thoracolumbar fascia represents a grouping of fascia and several muscles. Paraspinal muscle group and abdominal musculature are other important anatomical support for the back. Remember that muscle groups for the anterior and posterior legs are instrumental in lumbar biomechanics. III. ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ LBP 12/20/05 History Location- consider if dermatomal Vs nondermatomal pattern ? Radiation- radiation into the leg is common in many nonradicular syndromes. The term sciatica is used frequently in clinical practice and the literature. A widely agreed on definition of sciatica is unavailable. Perhaps the term radiculopathy is more clinically accurate and should reflect radiation of pain below the knee. The implication is that nerve root irritation exists. The most common causes of pain radiating into the distal lower extremity are HNP and lumbar stenosis. Mechanism- lifting, torsional forces, car accidents. Duration- 85% of all back pain will resolve in 2 weeks. (depends on end point measured) Associated symptoms- paresthesias, paresis, fever, weight loss, urinary/bowel incontinence. Paresthesias may be circumferential or dermatomal. Sensitivity and specificity of paresthesias (indicating HNP) are low, 75% and 15%, respectively. True radicular sxs indicate possibility of nerve impingement or irritation (herniated nucleus pulposus [HNP] or OA). Associated fevers, weight loss and anorexia may indicate infection or cancer. Bowel or bladder abnormalities, especially urinary retention, may indicate cauda equina syndrome, a surgical emergency. Initial treatment- has the patient used ice/heat, specific medication, done any exercises? PMHx- other musculoskeletal disorders, GI abnormalities, dermatologic disorders, cancer. This part of the Hx is important for a number of reasons. Peptic ulcer disease or reflux disease in a patient will affect medication choices. In addition, patients with dermatologic or GI disturbances coupled with musculoskeletal problems may have a rheumatologic condition. In patients over 50 years old with back pain and a prior Hx of cancer, consider bony mets. PSHx- has the patient had prior surgery? If so, gadolinium-enhanced MRI is more useful than unenhanced MRI in differentiating scar tissue from infection, Ca and HNP. 3 LUMBAR STRAIN: Back to the Basics Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] Estimated accuracy of medical history in diagnosis of spine disease causing low back problems References Deyo and Diehl Waldvogel and Vasey Unpublished data[a] Disease to be detected Medical history red flags Cancer Age >= 50 Previous cancer history Unexplained weight loss Failure to improve with 1 month of therapy Bed rest no relief Duration of pain > 1 month Age > 50 or history of cancer or unexplained weight loss or failure of conservative therapy IV. LBP 12/20/05 0.31 0.90 > 0.90 0.50 0.46 0.81 1.00 0.60 Spinal osteomyelitis Intravenous drug abuse, UTI, or skin infection 0.40 NA Compressi on fracture Age >= 50 Age >= 70 Trauma Corticosteroid use 0.84 0.22 0.30 0.06 0.61 0.96 0.85 0.995 Sciatica 0.95 0.88 Pseudoclaudication Age >= 50 Positive responses 4 out of 5 Age at onset <= 40 Pain not relieved in supine position Morning back stiffness Duration of pain >e;3 months 0.60 0.90 [b] 0.23 1.00 0.80 0.64 0.17 NA 0.70 0.82 0.07 0.49 0.59 0.54 Deyo and Tsui- Herniated wu, Spangfort disc Turner, Ersek, Spinal Herron, et al. stenosis Gran True-positive True-negative rate rate (sensitivity) (specificity) 0.77 0.71 0.31 0.98 0.15 0.94 Ankylosing spondylitis Physical Exam A. Inspection- deformities, scoliosis, erythema, ecchymosis, gait, heel and toe walking B. Palpation- point tenderness (bony and soft tissue) 4 LUMBAR STRAIN: Back to the Basics Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] C. Range of Motion- measure forward flexion in inches from the floor N.B. Signs of slow deliberate gait, decreased lumbar lordosis and limited range of motion are important. However, they have low diagnostic utility, since many causes of acute low back pain will manifest these signs. D. Neurovascular Assessment (most important is L4-S1): individually test heel and toe walking. Minor asymmetry is common. A positive test should show marked asymmetry. Nerve Root Sensory Reflex Motor L4 Anterolateral thigh Medial ankle Patellar Tibialis anterior L5 Posterolateral thigh Dorsum of ankle ? Posterior tibialis Extensor hallucis longus S1 Lateral ankle Achilles Peroneus Cross innervation is common and may result in misinterpretation. For screening purposes, extensor hallucis longus (L5) is most important. Remember that differentiating a peripheral nerve abnormality is necessary. Posterior tibialis and gluteus medius muscles are innervated by L5 nerve root, but not the peripheral peroneal nerve. Note: these tests have only moderate sensitivity and specificity for nerve root irritation. E. Special Tests ¾ Straight leg raise (SLR) + ankle dorsiflexion: pt supine, raise leg to 30-60°; + test is pain that radiates into the calf. Also, crossed SLR = SLR in unaffected limb exacerbates radicular pain in affected limb. LBP 12/20/05 5 LUMBAR STRAIN: Back to the Basics Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] ¾ Seated straight leg raise: With pt seated, examiner passively extends the knee; + test produces radicular pain. ¾ Modified SLR (? Lasegue's test): hip flexed to 90°, knee flexed to 90°, this should not cause pain if HNP; examiner then extends the knee until nerve root is stretched. Pain with knee extension may indicate nerve root irritation demonstrated with HNP or impingement with OA. ¾ Bowstring sign: SLR until pain, then flex the knee. This should reduce/extinguish pain if nerve root irritation. All of these variants on the SLR theme should be considered sensitive, but not specific for nerve root irritation. Reports of sensitivity and specificity range from 96-97% and 1015%, respectively. To date, studies have not been very precise in defining a positive test (which makes reproducibility of these tests difficult). Also note that reports on crossed SLR improves specificity (at the expense of sensitivity) to 85-95% (sensitivity from 20-30%). Test Sensitivity (%) Specificity (%) PV+ (%) SLR (ipsilateral) 96-97 10-15 70 Crossed SLR 20-30 85-95 80 ¾ ¾ ¾ ¾ ¾ FABER test = Flexion ABduction External Rotation of the hip: this position may cause pain in SI joint pathology. Pelvic rock test- the examiner grasps B/L ASIS anterior pelvis and pushes posteriorly. Pain at the SI joint indicates SI joint pathology. One-leg extension (or Arabesque) test: pt stands on one leg with back in extension (examiner supports); + test of pain may indicate spondylolysis. Hamstring flexibility- pt supine, hip and knees both at 90° flexion; examiner attempts to passively straighten leg. Measure from line perpendicular to floor. Leg length evaluation- measure from ASIS to medial malleolus (in cm). Estimated accuracy of physical examination for lumbar disc herniation among patients with sciatica LBP 12/20/05 6 LUMBAR STRAIN: Back to the Basics Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] Truenegative rate (specificity) Comments References Test Truepositive rate (sensitivity) Hakelius and Hindmarsh; Kosteljanetz, Espersen, Halaburt, et al. Ipsilateral SLR 0.80 0.40 Positive result: leg pain at < 60 degrees Hakelius and Hindmarsh; Spangfort Crossed SLR 0.25 0.90 Positive result: reproduction of contralateral pain 0.35 0.70 HNP usually at L4-L5 (80 degrees) Ankle dorsiflexion weakness Hakelius and Hindmarsh; Great toe Kortelainen, Puranen, Koivisto, extensor et al. weakness Hakelius and Hindmarsh; Spangfort 0.50 0.70 Impaired ankle reflex 0.50 0.60 Kortelainen, Puranen, Koivisto, Sensory loss et al.; Espersen, Halaburt, et al. 0.50 0.50 0.50 NA 0.06 0.95 < 0.01 0.99 Hakelius and Hindmarsh; Spangfort Aronson and Dunsmore Hakelius and Hindmarsh Hakelius and Hindmarsh Patellar reflex Ankle plantar flexion weakness Quadriceps weakness HNP usually at L5-S1 (60 degrees) or L4-L5 (30 degrees) HNP usually at L5-S1; absent reflex increases specificity Area of loss poor predictor of HNP level For upper lumbar HNP only Note: Sensitivity and specificity were calculated by Deyo, Rainville, and Kent. Values represent rounded averages where multiple references were available. All results are from surgical case series. HNP = herniated nucleus pulposous. SLR = straight leg raising. V. Radiology A. Views- my L-spine series includes AP and lateral views. If the patient is younger and spondylolysis/listhesis is a consideration, bilateral oblique views will be diagnostic. Consider standing films if a question of spondylolisthesis or OA. It has been demonstrated that obtaining AP and lateral films in the standing position may increase the amount of slip (of vertebral body L5 on S1) from 25-40%. This will have great impact grading of spondylolisthesis. OA is readily LBP 12/20/05 LUMBAR STRAIN: Back to the Basics 7 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] seen on AP and lateral films. Degenerative changes on plain films are common in older individuals but have demonstrated a poor correlation with clinical symptoms. Plain films may also assess for instability. While still being debated, current consensus is that > 3mm of difference between two vertebrae on lateral x-ray may indicate instability. A number of authors suggest obtaining x-rays if sx duration > 6 weeks, h/o trauma, sxs of tumor (constitutional sx, wt loss). B. MRI- very useful for visualizing an HNP, tumor, infection in symptomatic individuals. A number of studies have demonstrated a high incidence (up to 30%) of MRI changes consistent with disc protrusion in asymptomatic pts! Must correlate findings with clinical presentation. Does the Add gadolinium if prior history of surgery. This enhancement will differentiate scar tissue from cancer and HNP. C. CT-myelogram- adjunctive test. Some authors recommend this test (myelogram followed by CT scan) for symptoms of neurogenic claudication. Their rationale is based on better visualization of bone and hypertrophic spurs, assessment of anatomy of pedicles (important in planning of operative reconstruction). D. Electromyogram (EMG): probably overused as a diagnostic tool in LBP. We tend to rely more on historical and physical factors for diagnosis. In addition, this test does not usually change treatment plans, but may add to pt morbidity. This test is more useful when the diagnosis is in question or if seriously considering a peripheral neuropathy. VI. LBP 12/20/05 Management A. RICE (Rest, Ice, Compression, Elevation) B. Pharmacologic intervention ¾ Anti-inflammatory meds (NSAID's) are common first line agents. Ibuprofen is just as effective as the newer, fancier NSAID's. If one class does not work, consider switch to another class of anti-inflammatory med. Remember to allow up to 7-10 days for full anti-inflammatory effect. In patients with Hx of PUD/GERD, before the release of COX-2 inhibitors we would often consider addition of a prostaglandin analog to protect the stomach (misoprostol [Cytotec] 100-200 µg PO TID). Arthrotec provides a combination of diclofenac and cytotec. Dosages are 50 and 75 mg diclofenac/0.2 mg misoprostol. These are expensive and can cause diarrhea, but still should be considered, especially if COX-2 is contraindicated. ¾ COX-2 selective NSAID's minimal effects on COX-1 receptors, and thus minimal gastrointestinal and clotting effects. In some studies celicoxib (Celebrex) has caused no more adverse GI effects than placebo. Efficacy for inflammation has been comparable to other NSAID's. Caution with PMHx of CAD. LUMBAR STRAIN: Back to the Basics 8 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] ¾ ¾ ¾ ¾ ¾ Acetaminophen- demonstrated to be as efficacious as an anti-inflammatory dose of ibuprofen in relief of OA-type pain. Opiates- consider narcotic use in acute, severe pain (3-4 days). There is no support in the literature for their use after this. They may also interfere with attempts at rehabilitation phase. Muscle relaxers- efficacy has been questioned repeatedly. I tend to use sparingly. Again, they may interfere with rehabilitation. Multiple authors suggest, "Treat the pain and the muscle spasm will rescind." Antidepressants- multiple studies demonstrate analgesic effect of antidepressants, especially tricyclics. Can also assist with sleep disturbances. Usual dose is generally less than that required for treatment of depression. Neuroleptics- examples include neurontin (900-1800mg/D ÷ TID), tegretol (4001200mg/D ÷ BID-QID) and Lyrica (150mg BID). Adjunct therapy for nerve root irritation/peripheral nerve pain. Efficacy in these clinical situations to be determined. C. Rehabilitation 1. Home exercise program- Three types: ¾ William's flexion exercises ¾ McKenzie's extension exercises ¾ Hamstring flexibility exercises 2. Physical Therapy- may help with modalities (cryotherapy, ultrasound, electric stimulation, iontophoresis, massage). Will also lay-on hands and spend more time educating patients on proper lifting techniques, sitting techniques, etc. 3. Consider heel lifts or orthotics (shoe inserts) if biomechanical abnormalities. D. Epidural injections ¾ Frequently used by pain control centers. First reports of their use in 1901 (cocaine). Efficacy controversial. Balagué (1996) analyzed available randomized controlled trials regarding the efficacy of these techniques. Half of the studies demonstrated efficacy better than control and half did not. He recommends no more than three injections at 1 to 2 week intervals. VI. Specific Disorders A. Lumbar strain- pull or overuse of the lumbar musculature. Hx- may be acute pull, or insidious onset. Pain localized to the low back, buttocks and into posterior thigh. Usually not true radicular pain. LBP 12/20/05 LUMBAR STRAIN: Back to the Basics 9 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] PE- pain to palpation of paraspinal musculature. Negative straight leg raise. Normal L1S1 exam. Negative FABER and pelvic rock tests, indicating no SI joint involvement. May have poor hamstring flexibility. Dx- History and physical exam. X-rays if associated with trauma, or pain not improving despite adequate treatment. Natural History- 85% of lumbar strain improves within 2 weeks. The majority of the remainder will improve within the next 2 weeks. Rx- RICE, NSAID’s, exercises to stretch and strengthen the lumbar musculature, improve flexibility of the leg musculature. B. Spondylolysis and Spondylolisthesis Definition: Spondylo = vertebra, lysis = breakdown)defect in the pars interarticularis. Spondylolisthesis (listhesis = slippage) involves displacement of vertebral body anteriorly upon its subjacent member. Most common L5-S1; less common L4-5. Incidence: incidence in the general population 2-5%. Incidence in the athletic population increases to 11% in sports with a lot of extension maneuvers (gymnastics, volleyball, tennis, diving, wrestling, football and weight lifting). Spondy is usually bilateral (80%). Peak age 15 yrs old. Etiology: Physical forces- shear forces on the normal lumbar lordosis are increased in extension and further accentuated in combined extension and lateral flexion. Genetic factors also play a role in the development of spondy. There is a high incidence in identical twins and first-degree relatives (25-70%). Classification of Spondylolisthesis: Isthmian (spondylolytic)- most common cause of listhesis. Up to 50% of total cases Dysplastic (congenital)-20% of all cases. Failure of development of superior facets Degenerative- degeneration of superior facets or disc. Major cause of spinal stenosis Traumatic- disruption of posterior elements of neural arch other than pars (pedicles or lamina) Pathologic- osteoporosis, RA, tumor, infection LBP 12/20/05 Grade of Spondylolisthesis I- up to 25% L5 vertebral body on sacrum II- 25-50% III-50-75% IV- > 75% LUMBAR STRAIN: Back to the Basics 10 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] Hx- Most are asymptomatic. Of those symptomatic, back pain is most common complaint. May radiate to buttocks or thigh, but rarely do pts experience true radicular sxs. Pain often worse with activity (extension/lateral side-bending maneuvers). PE- Tender to palpation of paraspinal musculature. May appreciate a step-off in listhesis > 50% (grade III or more). Hamstring tightness or spasm commonly present. Occasionally a gait abnormality will be demonstrated (usually pelvic waddle). X-ray¾ Plain films usually diagnostic. Obtain standing obliques. Visualize the "Scotty dog," it will have a fracture through its neck with spondy. This is the defect in the pars interarticularis. The lateral view will demonstrate grade of slip. If this slip is severe L5 will be situated anterior to the sacral promontory. On the standing AP x-ray an "inverted Napoleon's hat" sign will be apparent. Clinically, this puts the cauda equina at risk for compromise. Standing films may increase amount of slip up to 24-40% more than non-standing films. ¾ Triple phase bone scan with technetium may assist in the acuity of the defect. Just because a defect is seen on x-ray does not mean it is the cause of symptoms. This test is better for younger patients. In pts with OA, less helpful 2° false positives. Also not recommended in asymptomatic pts or with sxs > 1 yr. Rx- treatment for most cases of spondylolysis is nonsurgical. The consideration of a back brace has been discussed in the literature. Bracing occurs if bone scan is positive. The most common type of brace used is the TLSO (thoracolumbar sacral orthosis). Its purpose is to limit amount of motion at the lumbar spine, though its effectiveness has been questioned. Reported duration of bracing is varied. Most commonly cited is 6 months in TLSO (23 hrs/day), 6 months wean from brace (decrease to 18 hrs, then 12 hrs, then 6 hrs during the 6 months). Others favor 3 months in/ 3 months wean. In most cases of spondylolysis, the above regimen coupled with supportive care will produce asymptomatic patient. Serial x-rays (q 6-12 months?) may be necessary to document any listhesis- especially in adolescence during growth spurt. One growth plates close, further slippage is unlikely. Return to sport when full, painless range of motion, good strength, good aerobic capacity. LBP 12/20/05 LUMBAR STRAIN: Back to the Basics 11 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] Indications for Surgery Risk Factors for Slip Progression Progression of slippage Neuro deficit Refractory pain Persistent gait abnormality Slip angle > 50° in skeletally immature Age- listhesis progresses mainly in 10-15 yrs Sex- female more likely to progress Symptoms- with recurrent sxs, more likely to slip Grade of slip- grades III, IV more likely to progress Class of listhesis- dysplastic (congenital) C. Herniated nucleus pulposus (HNP) 1. Leakage of nucleus pulposus into the foramina or spinal canal. Most common direction of leakage is posterolateral. Most common site is L5-S1, followed by L4L5(95% of clinically relevant HNP at these two levels). Average age = 42 yrs (range 18-68). Classified as: ¾ Bulge- usually not clinically relevant. ¾ Protrusion- extends into foramen or spinal canal ¾ Extrusion- extends further ¾ Sequestration- free fragments Hx- Back pain, leg pain, or both. Frequently back pain develops first, and then leg pain begins as back pain recedes. Worsened with forward flexion, prolonged standing/sitting and Valsalva maneuvers. The prevalence of HNP in acute low back pain is low, ~ 1%. PE- + SLR/crossed SLR/seated SLR. + motor weakness and decreased reflexes to the corresponding affected nerve root. Dx- x-rays- disc space narrowing is not a useful guide to assess for possible HNP. X-rays most useful in r/o other disorders. MRI may demonstrate HNP well (but clinical correlation required). Remember; up to 30% of asymptomatic pts will demonstrate disc protrusion on MRI! (60% of ASx pts will have a disc bulge!!). Natural history- most studies indicate that nonsurgical management = surgical management at one year. There is some indication that the further the NP protrudes/extrudes the more likely that the body's scavenger system (phagocytosis, etc.) will eradicate the NP. This leads to the eventual resorption of LBP 12/20/05 LUMBAR STRAIN: Back to the Basics 12 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] this material. Note: Symptomatic improvement occurs prior to this resorption. Rx- usually nonsurgical. NSAID's, antidepressants, relative rest and cryotherapy are initial treatment options. After acute sxs improve, aggressive P.T. plus modalities will help. Mobilization, strengthening (usually McKenzie's extension exercises) and flexibility are key to sx improvement. Antidepressants: Most supportive data on TCA’s (elavil) and symptom improvement. Dose is usually less than needed for Rx of depression. Consider SSRI’s as well, though less support in literature. Also consider Neurontin or Lyrica. Average dose of neurontin is 9001800 mg a day (divided TID-QID). Average dose of Lyrica is 150mg BID. Most common side effect is somnolence. Epidural injections with local anesthetics or steroids have been suggested. Over twenty studies have looked at the efficacy of epidural injections. Half demonstrate improvement, half do not. Surgical treatment for progressive neurologic deficits, intractable pain, lack of expected response to P.T./rehab regimen of adequate length (8-12 weeks). Pts with predominantly calf pain seem to respond better to surgery than those with predominantly back pain. D. Piriformis syndrome The piriformis syndrome is somewhat controversial in that its diagnosis and treatment have not been well defined in the literature. This syndrome may represent up to 5% of the cases of patients with "sciatic" type pain. Often considered a diagnosis of exclusion. ? Is this the same as wallet neuritis? Anatomy- the piriformis muscle is located underneath the gluteal musculature, but on top of the sciatic nerve. If this muscle is hypertrophied or in spasm, it may impinge upon the sciatic nerve and produce Hx and PE factors consistent with irritated nerve root. Hx and PE- Variable. Sitting may exacerbate pain, especially after long trips. In addition, there may be pain with resisted external rotation or passive internal LBP 12/20/05 LUMBAR STRAIN: Back to the Basics 13 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] rotation of the hip (AKA Freiberg's sign). There usually is pain to deep palpation of the sciatic notch. While sensory changes may occur in this syndrome, motor weakness is typically not present. Rx- Treatment is as above. In this case I would consider muscle relaxers in acute pain. Also, rigorous flexibility program specifically addressing the piriformis will help. Physical therapy modalities (include stretch and spray techniques) has been described. Some authors suggest piriformis muscle injection with local anesthetic. Surgery is reserved for recalcitrant cases that do not improve with nonsurgical treatment. E. Osteoarthritis (OA) Hx- lack of trauma, insidious onset of pain, worse upon awakening but improves within 30-60 minutes. PE- nonspecific; may demonstrate radicular signs if encroachment on nerve by spurs, etc. Usually with inflexibility, + limb length discrepancy. X-rays- classic spur formation that may encroach upon the foramina or spinal canal. Recall that the nerve root only occupies 25-33% of the foraminal opening. X-ray findings do not correlate well with intensity of symptoms. Rx- as above. Consider heel lifts for leg length discrepancy and vigorous flexibility program. Also, consider facet joint injections. F. Vertebral Compression Fracture(Osteoporosis) Hx- Acute vs subacute onset of localized back pain at site of fx. Most common levels for compression fx T8-L3. PE- nonspecific. Point tender paraspinal musculature and midline. Neuro exam usually normal. Dx- plain xray usually diagnostic. Consider CT if questions of bony fragments encroaching on spinal canal/cord. Rx- treat underlying osteoporosis! Calcium + vitamin D. Otherwise treatment as in section A. For some patients, vertebroplasty (fluoroscopic injection of cement) or kyphoplasty (injection of a balloon into vertebral body) may be helpful. G. Sacroiliac sprain Some authors question the existence of this clinical entity. Probably more common in pts with rheumatologic disorder (the sacroiliac joint possesses a synovial membrane). The SI joint does move ~ 5-7o. Hx and PE findings are very variable. Usually lacks true radicular components. Lacks neuro deficits. Some authors attribute positive FABER and pelvic rock tests LBP 12/20/05 LUMBAR STRAIN: Back to the Basics 14 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] to SI joint pathology. Rx- as mentioned above. Joint mobilization techniques by physical therapists may also give sx relief. H. Cauda Equina Syndrome A surgical urgency. Compromise of the cauda equina- the horses tail or whip. Associated with HNP or grade 4 spondylolisthesis. Hx and PE- Defined as progressive neurologic deficits with bowel or bladder dysfunction- mostly urinary retention. In fact, the sensitivity of urinary retention as a diagnostic “test” for cauda equina syndrome has such a high sensitivity that a negative “test” virtually rules out the possibility of cauda equina. Rx- surgical decompression and stabilization. LBP 12/20/05 LUMBAR STRAIN: Back to the Basics 15 Gaetano P. Monteleone, Jr., M.D. Division of Sports Medicine Dept of Family Medicine West Virginia University School of Medicine [email protected] REFERENCES Andersson GB, Deyo RA. History and physical exam in patients with herniated lumbar discs. Spine. 21:10S-18S, 1996. Assendelft WJ, Bouter LM, Knipschild PG. Complications of spinal manipulation- a comprehensive review of the literature. J of Fam Pract. 42(5):475-80, 1996. Balagué F. Injections and low back pain: outcome and randomized controlled trials. Bulletin- Hosp for Joint Diseases. 55(4): 185-90, 1996. Boden SD, Davis OD, Dina TS, et al. Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects. JBJS. 72A: 403-8, 1990. Boos N, Rieder R, Schade V, et al. The diagnostic accuracy of magnetic resonance imaging, workplace perception, and psychosocial factors in identifying symptomatic disc herniations. Spine. 20:2613-25, 1995. 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