Objectives

 Review the functional anatomy of lumbo-sacral spine

 List essential components of a LBP history, including RED
FLAGS
 Describe common causes of LBP
 Review proper indications for imaging and referral
 Review Physical Examination of LS spine
 Correlate pathology with pertinent physical findings
 Epidemiology
 Incidence of LBP:
 60-90 % lifetime incidence
 5 % annual incidence
 90 % of cases of LBP resolve without treatment within 6-12
weeks
 40-50 % LBP cases resolve without treatment in 1 week
 75 % of cases with nerve root involvement can resolve in 6
months
 LBP and lumbar surgery are:
 2nd and 3rd highest reasons for physician visits
 5th leading cause for hospitalization
 3rd leading cause for surgery

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 Disability
 Age and LBP:
 Leading cause of disability of adults < 45 years old
 Third cause of disability in those > 45 years old
 Prevalence rate:
 Increased 140 % from 1991 to 2000 with only125 % population
growth
 Nearly 5 million people in the U.S. are on disability for LBP

4
 Lifetime Return to Work
 Success of < 50 % if off work > 6 months

 25 % success rate if off work > 1 year

 Nearly 0 % success if return to work has not

occurred in 2 years

5
Differential Diagnoses
 Lumbar Strain
 Disc Bulge / Protrusion / Extrusion
producing Radiculopathy
 Degenerative Disc Disease (DDD)
 Spinal Stenosis
 Spondyloarthropathy
 Spondylosis
 Spondylolisthesis
 Sacro-iliac Dysfunction

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“Red Flags” in back pain
 Age < 15 or > 50
 Fever, chills, UTI
 Significant trauma
 Unrelenting night pain; pain at rest
 Progressive sensory deficit
 Neurologic deficits
 Saddle-area anesthesia
 Urinary and/or fecal incontinence
 Major motor weakness
 Unexplained weight loss
 Hx or suspicion of Cancer
 Hx of Osteoporosis
 Hx of IV drug use, steroid use, immunosuppression
 Failure to improve after 6 weeks conservative tx
Frequency of Back Pain Types
visceral 2%
2% visceral ,tumor
1% 1%
tumor,
,infection
infection,
inflammatory
inflammatory
arthritis
arthritis

97%
“mechanical”
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 Your patient with LBP has paresthesias in the lateral foot, decreased
toe-raise strength, diminished sensation lateral foot, and diminished
Achilles reflex. This is suggestive of dysfunction of which nerve root?
1. L4
2. L5
3. S1
4. S2
 Better anatomy knowledge
=
Better diagnoses and treatments
 Vertebra
 Body, anteriorly
 Functions to support weight
 Vertebral arch, posteriorly
 Formed by two pedicles and two laminae
 Functions to protect neural structures
 Biomechanics
80% 20%
Anterior Posterior

The 80-20 rule of Spine loading

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Ligaments
 Anterior longitudinal ligament
 Posterior longitudinal ligament
 Ligamentum flavum
 Interspinous ligament
 Supraspinous ligament
 Ligamentous

Anterior longitudinal ligament

Sciatica is defined
1. Pain radiating up the back
as…
25% 25% 25% 25%
2. Pain radiating to the thigh
3. Pain radiating below the
knee
4. Pain in the butt

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•L4
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PATIENT HISTORY
“OPQRSTU”
 Onset
 Palliative/Provocative factors
 Quality
 Radiation
 Severity/Setting in which it occurs
 Timing of pain during day
 Understanding - how it affects the patient
 Which one is NOT considered a
“red flag” of LBP?
1. History/suspicion of cancer 25% 25% 25% 25%
2. Age over 50
3. Fever or chills
4. Sciatica

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“Red Flags” in back pain
 Age < 15 or > 50
 Fever, chills, UTI
 Significant trauma
 Unrelenting night pain; pain at rest
 Progressive sensory deficit
 Neurologic deficits
 Saddle-area anesthesia
 Urinary and/or fecal incontinence
 Major motor weakness
 Unexplained weight loss
 Hx or suspicion of Cancer
 Hx of Osteoporosis
 Hx of IV drug use, steroid use, immunosuppression
 Failure to improve after 6 weeks conservative tx
 Onset
 Acute - Lift/twist, fall,
MVA
 Subacute - inactivity,
occupational (sitting,
driving, flying)
 Pain effect on:
 work/occupation
 sport/activity (during or
after)
 Other History
 Prior h/o back pain
 Prior treatments and response
 Exercise habits
 Occupation/recreational
activities
 Cough/valsalva exacerbation
Diagnoses & Red Flags
 Cancer  Fracture
 Age > 50  Age >50
 History of Cancer  Trauma
 Weight loss
 Steroid use
 Unrelenting night pain
 Failure to improve  Osteoporosis

 Cauda Equina Syndrome

 Infection  Saddle anesthesia
 IVDU
 Bowel/bladder
 Steroid use dysfunction
 Fever
 Loss of sphincter control
 Unrelenting night pain
 Failure to improve  Major motor weakness
Physical Examination

 Inspection
 Palpation
 Strength testing
 Neurologic examination
 Special tests
Approach to LBP
 History & physical exam
 Classify into 1 of 4:
 LBP from other serious causes
 Cancer, infection, cauda equina, fracture
 LBP from radiculopathy or spinal stenosis
 Non-specific LBP
 Non-back LBP
 Workup or treatment
 Diagnostic Tools
1. Laboratory:
• Performed primarily to screen for other disease etiologies
 Infection
 Cancer
 Spondyloarthropathies
• No evidence to support value in first 7 weeks unless with red flags
• Specifics:
 WBC
 ESR or CRP
 HLA-B27
 Tumor markers: Kidney Breast Lung Thyroid
Prostate

29
2. Radiographs:

• Pre-existing Degenerative Joint Disease (Osteoarthritis) is most

common diagnosis
• Usually 3 views adequate with obliques only if equivocal findings
• Indications:
 History of trauma with continued pain
 < 20 years or > 55 years with severe or persistent pain
 Noted spinal deformity on exam
 Signs / symptoms suggestive of spondylo-arthropathy
 Suspicion for infection or tumor

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3. Electromylogram (EMG):
 Measures muscle function
 Would not be appropriate in clinically obvious
radiculopathy
4. Bone Scan:
 Very sensitive but nonspecific
 Useful for:
 Malignancy screening

 Detection for early infection

 Detection for early or occult fracture

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33
5. Myelogram:

 Procedure of injecting contrast material into the spinal canal

with imaging via plain radiographs versus CT

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6. CT with Myelogram:
 Can demonstrate much better anatomical detail than Myelogram
alone
 Utilized for:
 Demonstrating anatomical detail in multi-level disease in pre-
operative state
 Determining nerve root compression etiology of disc versus
osteophyte
 Surgical screening tool if equivocal MRI or CT

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7. CT:
 Best for bony changes of spinal or foraminal stenosis
 Also best for bony detail to determine:
 Fracture

 Degenerative Joint Disease (DJD)

 Malignancy

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9. MRI
• Best diagnostic tool for:
 Soft tissue abnormalities:
• Infection
• Bone marrow changes
• Spinal canal and neural foraminal contents
 Emergent screening:
• Cauda equina syndrome
• Spinal cored injury
• Vascular occlusion
• Radiculopathy
 Benign vs. malignant compression fractures
 Osteomyelitis evaluation
 Evaluation with prior spinal surgery

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 Disc Degeneration: Findings?

Narrowing

Osteophyts

Endplate sclerosis

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Degeneration & Tears

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 Disc
Normal Bulge
Bony
Endplate Canal

Disc Classification

Protrusion Extrusion

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 Bulging

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 Protrusion

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 Protrusion

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 Extrusion

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Extrusion

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Extrusion

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 Treatment
 Pharmacological
 NSAIDS
 Muscle relaxents:
 Re-establish sleep patterns

 More useful in myofascial/muscular pain

 Membrane stabilizers
 TCA / Neurontin

 Re-establish sleep pain

 Reduce radicular dysesthesias

 Narcotics: rarely indicated

 Morphine, Oxy/hydrocodone, Oxymorphone,
Hydromorphone, Fentanyl, Methadone
 Steroids: more useful for radiculitis
 Non-narcotic analgesics: Ultram (Tramadol)

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 Physical Therapy
 Modalities
• Electrical Stimulation/TENS
• Postural Education / Body Mechanics
• Massage / Mobilization / Myofascial Release
• Stretching / Body Work
• Exercise / Strengthening
• Traction
• Pre-conditioning / Work-conditioning

 Injections (Neural blockade)

• Epidural blocks
• Facet blocks
• Trigger point
• SI joint

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Epidural Steroid Injections
 Indicated for radiculopathy not responding to
conservative mgmt
 Conflicting evidence
 Small improvement up to 3 months
 Less effective in spinal stenosis
 Surgery

 Laminectomy
 Hemilaminectomy
 Discectomy
 Fusion
 Instrumented
 Non-instrumented fusion
 Minimally Invasive Spine Surgery (MISS)
 Kyphoplasty
 Percutaneous Disc Decompression (PDD)

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Break for
Physical Examination Hands-on
Session
Inspection
 Observe for areas of erythema
 Infection
 Long-term use of heating element
 Unusual skin markings
 Café-au-lait spots
 Neurofibromatosis
 Hairy patches, lipomata
 Tethered cord
 Dimples, nevi (spina bifida)
Inspection (cont.)
 Posture
 Shoulders and pelvis should be level
 Bony and soft-tissue structures should appear symmetrical
 Normal lumbar lordosis
 Exaggerated lumbar lordosis is common characteristic of
weakened abdominal wall
Neurologic Examinaion
 Includes an exam of entire lower extremity, as lumbar spine
pathology is frequently manifested in extremity as altered
reflexes, sensation and muscle strength
 Describes the clinical relationship between various muscles,
reflexes, and sensory areas in the lower extremity and their
particular cord levels
Neurologic Examination
(T12, L1, L2, L3 level)
 Motor
 Iliopsoas - main flexor of hip
 With pt in sitting position, raise thigh against resistance
 Reflexes - none
 Sensory
 Anterior thigh
Neurologic Examination
(L2, L3, L4 level)
 Motor
 Quadriceps - L2, L3, L4, Femoral Nerve
 Hip adductor group - L2, L3, L4, Obturator N.
 Reflexes
 Patellar - supplied by L2, L3, and L4, although essentially an
L4 reflex and is tested as such
L2, L3, L4 testing
Neurologic Examination
(L4 level)
 Motor
 Tibialis Anterior
 Resisted inversion of ankle
 Reflexes
 Patellar Reflex (L4)
 Sensory
 Medial side of leg
Neurologic Examination
(L5 level)
 Motor
 Extensor Hallicus Longus
 Resisted dorsiflexion of great toe
 Reflexes - none
 Sensory
 Dorsum of foot in midline
Neurologic Examination
(S1 level)
 Motor
 Peroneus Longus and Brevis
 Resisted eversion of foot
 Reflexes
 Achilles
 Sensory
 Lateral side of foot
Special Tests
Tests to stretch spinal cord or sciatic
nerve
Tests to increase intrathecal pressure
Tests to stress the sacroiliac joint
Tests to Stretch the Spinal Cord or
Sciatic Nerve
Straight Leg Raise
Cross Leg SLR
Kernig Test
Test to increase intrathecal pressure
Valsalva Maneuver
Reproduction of pain
suggestive of lesion
pressing on thecal sac
Kernig Sign

Pain relieved
Pain present
Tests to stress the Sacroiliac Joint

FABER Test
FABER test:
Flexion
A-
Bduction
External
Rotation
 Management of an acute low back muscle strain
should consist of all the following EXCEPT:
1. X-rays to rule out a
fracture
2. Educate the patient
on generally good
prognosis
3. Non-opiate analgesics
4. Remain active