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Diagnosing and TreatingLumbar Spine Disorders:Evidence-BasedGuidelines

Robert Metzger, DNP, APRN, FNP-BC

Objectives:n Understanding of basic lumbar anatomy.n Differentiate the etiologies, physiologies, physical

examination techniques, and differential diagnoses of common lumbar spine disorders using EBP guidelines.

n Recognize presented lumbar spine disorders through a review of lumbar radiographs.

n Construct EBP recommended nonpharmacol ogical and pharmacological treatments, as well as patient education, for lumbar spine disorders.

n Describe overview of new research endeavors relating to some lumbar spine diagnoses.

This presenter has no conflicts of interest

to report

LUMBAR SPINEn Vertebrae

¨ Kidney shaped bodies

¨ ML > AP dimensions

- Smaller Transverse Process

- Spinal Processes are large, square, and horizontal

- Foramen- Vertebral: wider

and triangular- Intervertebral: 33%

occupied by nerve

Lumbar Vertebral Joints

n Facet Joints - formed by the superior & inferior articular processes of opposing vertebrae

n Pars Interarticularis – the space between the superior & inferior articular processes of the same vertebra

INTERVERTEBRAL DISCSn Discs are located between the endplates of the

vertebral bodiesn Most important and unique articulating system in

the spine, allowing for multi-planar motionn Make up ¼ of the total length of the spine column n Largest avascular structure in the human bodyn Cartilaginous joint of the motion segmentn Shock absorbers of the spine, which are so strong

that with compression the vertebral bodies will fail before the discs

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Intervertebral Discsn 2 Components

¨ Annulus Fibrosusn Outer part of the discn Collagen fibers w/ water

and proteoglycansn Layered in concentric

layers called Lamellae, which are thicker and more numerous in the anterior portion of disc

¨ Nucleus Pulposusn Interior substance of the

disc (gelatinous)n Increased water and

proteogylcan content (85% Water content)

Ligaments (brief overview)n Anterior Longitudinal

Ligamentn Posterior Longitudinal

Ligamentn Ligamentum Flavum

(noncontinuous, yellow color)

n Interspinous Ligament (connects the SPs)

n Supraspinous Ligament (connects the tips of the SPs)

n Intertransverse Ligament (connects the TPs)

SPINAL CORD / NERVES

n Spinal cord ¨ Begins at Foramen Magnum and

continues w/ terminus at Conus Medullaris near L1

n Cauda Equina¨ Collection of nerves which run from

conus medullaris to the filum terminale

n Nerve Roots¨ Canal is broader in cervical/ lumbar

regions due to the large number of nerve roots

¨ Branch off the spinal cord higher than actual exit through the intervertebral foramen

n In lumbar region, the nerve root exits below the vertebral body

n Example:At the level of the L4/5 disc, the L4 nerve roots exit through the neuroforamen and the L5 nerve roots traverse along within the thecal sac

DERMATOMESn Areas of skin innervated by sensory fibers from a single spinal nerve Lumbar Diagnoses: Incidence / Prevalence

n 5th for reasons US patients present for an office visit n 2nd most common chief complaintn Prevalent among all age groups, especially

adolescents to elderlyn LBP care / economic losses exceeds $90-100 billion

annuallyn Most common reason for disability for patients ≤ 45

years oldn Prevalence for continued disability is 60-80% after

one yearn Patients with h/o prior work absenteeism showed a

40% prevalence for future occurrences

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Lumbar Diagnoses – 2 Main DifferentiationsLow Back Pain

(w/o lower extremity pain)¨ Non-specific LBP (NSLBP)

n Degenerative Disc Diseasen Facet Joint Hypertrophyn Vertebral Endplate Sclerosisn Vertebral Osteophytes

¨ Lumbar Stenosis *¨ Lumbar Disc Displacement *¨ Spondylolysis &

Spondylolisthesis *¨ Lumbar Fractures¨ Scoliosis

* = may sometimes cause leg pain

Low Back Pain (w/ lower extremity pain)

¨ Lumbar Stenosis ¨ Lumbar Radiculopat hy (r/t

Lumbar Disc Displacement)

¨ Lumbar Radiculopat hy (r/t Facet Synovial Cyst)

¨ Lumbar Radiculopat hy (r/t Spondylolisthesis )

¨ Exists in 25-57% of all lumbar cases

Non-specific Low Back Pain (NSLBP)n Mechanical type pain that varies with

activity and posturen Unrelated to a recognizable pathology,

osteoporosis, structural deformity, or radicular syndrome

n Usually difficult in identifying a causen Mostly associated with muscular strainn Typically is related to degenerative

changes in the disc, facet joint hypertrophy, vertebral endplate sclerosis, or vertebral osteophytes

n Presentation¨Back pain increased by changes in

position or with flexion of the spine¨Pain noted with prolonged sitting

(differentiating symptom)¨ If located midline over the spinous

processes, 84% association with DDD

Degenerative Disc Disease (DDD)n Loss of normal tissue structure and

function due to the aging process. n Usually is a gradual process,

however acute trauma will accelerate the process

n Changes within the intervertebral disc¨ Water and proteoglycan

decrease in the nucleus first, then the annulus

¨ Fibers of the annulus become distorted, tears may occur in the lamellae decreasing the strength of the disc

n Most common level is L4/5n By age of 50, 95% of people will

have evidence of DDD

n Effects the entire motion segment¨ Facet joints override

and wear at the hyaline cartilage

¨ Disc shrinks and the disc space narrows

¨ Loads are transferred from disc to the endplates

¨ Osteophytes may develop and encroach on neurological structures

Spinal Stenosisn Refers to narrowing present in the neuroforaminal

spaces, lateral recesses, or central canaln Primary (Developmental/Congenital) or Secondary

(Acquired, which is the most common)n Secondary Stenosis

¨Acquired through degenerative changes, pathological changes, or prior surgery

¨Typically found in the older population > 50 years old

¨L3/4, L4/5 are most involved lumbar segments¨Diagnosis and severity are largely dependent on

the history and physical examination

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Stenosis Symptoms¨ Presence or absence of LBP¨ Pain is typically improved with forward flexion (grocery cart test)

as the canal space increases and with rest¨ Neurogenic claudication

n Most common finding for lumbar stenosis severely impacting patients’ function and quality of life

n Radiating pain into the bilateral / unilateral buttock, anterior thigh, or posterior pain down the leg to the calf and sometimes to the feet (usually bilateral)

n Worse with standing, walking upright, and extensionn Can include sensation of weakness and/or heaviness,

paresthesias, fatigue, hamstring tightness, and occasional nocturnal cramps

n Important to differentiate from vascular claudication, which is pain relieved upon standing alone, typically below the knee, unchanged by flexion of the spine, and with a fixed duration of walking

Lumbar Disc Displacement (Herniation)n Most frequent surgically treated pathologies of the spinen Commonly occurs at L4/5 & L5/S1 (regions with the

greatest ROM and axial loading)n Internal disruption to the disc is permanent due to the

disc being avascularn Four degrees of herniation

1. Fissure / Bulging2. Protrusion3. Extrusion4. Fragmented / Segmented

n Symptoms are similar to NSLBP or Lumbar Radiculopathy, depending on leg involvement

Lumbar Radiculopathyn Pain radiating from the lower

back into the legs as a result of impingement on the nerve roots

n Causes:¨ Lumbar Disc Displacement

(primary cause)¨ Facet Synovial Cyst¨ Spondylolisthesis

n Typically in younger patients

Radiculopathy Symptomsn Pain radiating from the lumbar region that is primarily

unilateral and greater than patients LBP, with some patients not having any LBP

n Typically worse during rest or in the nightn Paresthesias (burning, numbness, tingling) that follow a

dermatomal pattern (mostly along L4-S1)n Muscle Weakness, typically below the kneen Changes in patellar or Achilles reflexesn Pain may be increased with Valsalva

maneuvers

Spondylolysis & Spondylolisthesis

n Confusing Terminology:¨Spondylosis – degenerative changes in

vertebrae at the disc and facet joints¨Spondylolysis – defect in the vertebrae in area

of pars interarticularisn Descriptive Terminology:

¨Anteriolisthesis – anterior / forward¨Retrolisthesis – posterior/ backward¨Lateral – sideways movement

Spondylolisthesisn Slippage of one vertebrae in relation to the adjacent

vertebraen Incidence is approximately 3-4% of all populationsn Strong hereditary factorn Noticed more in gymnasts, football linemen, and

weightliftersn Most slips are related to a deficit in the pars interarticularisn Disc degeneration is associated with almost all forms of

spondylolisthesisn Symptoms

¨ Most common complaint is LBP¨ Radiation into the buttocks and occasionally posterior

thighs

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SPINAL FRACTURESn Most common fractures seen in an outpatient setting:

¨ Compression / Burstn Associated with falls from greater than 6 feet or any

fall in a patient with osteoporosis¨ Transverse Process / Spinous Process¨ Burst (severe compression) or Facet fractures are more

common in emergent settingsn Trauma to spine implies injury to any or all anatomical

structures: bony elements, soft tissues, and neurological structures

Scoliosisn Defined as a lateral curvature of the spinen Adult scoliosis: Idiopathic / Degenerative

¨ Idiopathicn Continued progression from adolescent

¨ Degenerativen Onset of scoliosis in previous straight spinen Result of asymmetric deterioration of spinal components,

caused by spondylosis

The History

& Physical

Exam

Key Items in History n Provider should classify LBP from back pain with lower

extremity painn Should be specific regarding locations of pain (midline,

lateral, bilateral), especially if leg pain is present¨ Determination of leg pain aids in differentiating between stenosis

and radiculopathy

n List the degree of pain on the visual analog scalen Activity difficulties (walking, sitting, standing,

flexion/extension)n Sensorimotor deficitsn Aggravating / Alleviating factorsn Prior beneficial / failed treatments, especially in regards

to medication regimens

Key Items in Physical Examinationn Should encompass inspection and palpation for alignment,

tenderness, and/or erythema / edeman Neurological Assessment

¨ Motor assessmentn Muscle strength (graded on 5 scale) or atrophy

¨ 5 – Normal strength (full resistance)¨ 4 – Movement possible against some resistance by examiner¨ 3 – Movement possible against gravity, but not against examiner’s resistance¨ 2 – Movement possible, but not against gravity (test in horizontal plane)¨ 1 – Muscle flicker, but no movement¨ 0 – No contraction

¨ Sensory assessment – tactile to detect dermatomal deficits¨ Reflex Testing¨ Special Tests

n Cardiovascular Assessment (bruits, decreased pulses, pitting edema)

Special Tests (LUMBAR):n Gait Testing (Motor) –

¨ Normal Gait Pattern ( no evidence of foot drop)¨ Heel Walking – If difficult, can indicate L4/5 involvement¨ Tip Toe Walking – If difficult, can indicate S1 involvement

n Straight Leg Raise [AKA Laseque’s test] (Neurological) –¨ Perform if history includes nerve root symptoms¨ Pt lays supine or sits upright while provider passively raises

each leg individually with knee extended until the patient complains of pain down the back of the leg. Once pain is elicited, drop the leg slowly until they feel no pain, then dorsiflex the foot.

¨ Positive if pain is elicited within the leg between 35-70 degrees of elevation. Dorsiflexion should increase this pain (if not, likely hamstring tightness). Hamstring pain involves only the posterior thigh. Back pain alone is not a positive SLR.

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Special Tests (LUMBAR) – cont.:n FABER [AKA Patrick’s Maneuver & LaFebere test] (Motor) –

¨ Flex the knee and place ankle above contralateral knee. Apply downward force onto the flexed knee to stress the lower back, SI joint, & hip.

¨ Positive – pt will elicit pain that should point to the source of pathology

n Femoral Nerve Stretch (Neurologica l) –¨ Opposite of SLR and tests L3 (femoral nerve)¨ Conducted in standing or prone position with back straight,

examiner grasps the limb flexing the knee while slightly hyperextending the hip

¨ Positive – produces L2-4 radicular symptoms to the anterior knee

n Rectal Assessment (Neurologic al) –¨ Performed for c/o saddle paresthesias or bowel incontinence

n Special Reminders¨ Multiple Myotome / Dermatome Dances / Sayings ¨ Umbilicus – Level of L3/4 ¨ Line across iliac crests – Level of L4/5

n DTR’s¨ Standard 2+ and equal

bilaterally¨ Positive if < or > than 2+

unilaterally or bilaterallyn Ankle Clonus

¨ Quick dorsiflexion of the relaxed ankle joint.

¨ Positive with repetitive (4+) twitching/pulsing of the foot

n Babinski’s¨ Stroking of lateral aspect of

sole of foot from the heel to the toes

¨ Positive with extension of great toe and fanning of four small toes

Long Tract Signs (Pathologic Reflexes)[suggestive of upper motor neuron lesions]

Lumbar Neurological Examination Key PointsT12 – L3 M Hip Flexion (Knee Raising - Iliopsoas) – L2, Quadriceps (Knee Extension) – L3,

Hip AdductionR NONES L1 – Proximal third of Anterior Thigh

L2 – Middle third of Anterior ThighL3 – Distal third of Anterior Thigh (to knee)

L4 M Foot Inversion (Tibialis Anterior), Ankle DorsiflexionR Patellar Tendon reflexS Medial Leg (Tibial Crest – Medially), Medial Foot, and Medial Great Toe

L5 M Hip Abduction (Gluteus Medius), Great Toe Extension (EHL), 2nd-5th Toe Extension (EDL)

R NONES Lateral Leg (Tibial Crest – Laterally), Dorsum of Foot

S1 M Foot Eversion, Calf Raises (Gastrocnemius), Hip Extension (Gluteus Maximus)R Achilles Tendon ReflexS Lateral Foot, Portion of Plantar Surface

S2 – S4 M Intrinsic Muscles of Foot, Bladder motor supply, Knee flexion – S2 R Superficial Anal Reflex (Sphincter Wink)S Concentric Rings – S2 – Outermost Ring, S3 – Middle Ring, & S4/S5 –

Innermost Ring

Differential Diagnosesn Primary EBP goal = rule out serious pathology,

present in 5% of cases (red flags)¨ Spinal Cancer

n Age greater than 50n Prior h/o cancer (prostate, thyroid, breast, lung, kidney)n Insidious onset, recent weight loss, night pain, pain at multiple sites,

esp. at rest, urinary retention, unresponsiveness to prior care¨ Spinal Fracture

n Age greater than 50n H/O osteoporosis, trauma, or chronic steroid use

¨ Spinal Infectionn Recent fever, h/o IVDA, prior or current infections, esp. from prior

lumbar ESIs, and immunocompression¨ Cauda Equina Syndrome

n Acute or worsening radicular symptoms, sensorimotor deficits, foot drop, saddle paresthesias, and/or bladder/bowel incontinence

n Secondary goal = classify patients as radicular or non-radicular LBP¨ Non-radicular major causes (lumbar strain/sprain, myofascial

pain, DDD)¨ Radicular (Lumbar Stenosis / Radiculopathy)

n Make sure to differentiate neurogenic claudication from vascular claudication

n Other possible diagnoses: ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis (DISH), aortic aneurysm, pancreatitis, or renal calculi

Diagnostic Examinationn Routine use is not

warranted based on current guidelines

n Should be reserved for patients with progressive neurologic involvement or if suspicious of an underlying pathology

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DiagnosticsX-raysn Provides basic evaluation of bone and disc spacing allowing visualization

of degeneration, fractures, and instability of the spinen AP/Lateral for pathology n Flexion/Extension added if concerned about spinal instabilityn Oblique added if concerned about spondylolysis / spondylolisthesis

(Scotty Dog)

Magnetic Resonance Imaging (MRI SCANS – non-radiation)n Primary diagnostic for neurologic al involvementn Adept at evaluation of soft tissue pathology (i.e. nerves, spinal cord, and

discs)n Order w/ contrast if prior surgery has been done to r/o scar tissue

involvement or tumorn Can be performed unless pt has pacemaker/defibri llator implant,

aneurysm clips, other motor run implants, spinal cord stimulators, or a bullet close to the spine

Computed Tomography (CT SCANS – high radiation)n Particularly good for detecting bone pathologyn May consider CT if patient had prior hardware and there’s concern for

artifact on MRI or lucency of the hardware

CT Myelogram (high radiation)n Secondary test if concern for neurological involvementn Needle is introduced into the subarachnoid space and contrast is

injected with the patient tilted on the table so the dye will go to the specific region we are testing

n AP/Lateral views of spine are then taken¨ Contrast appears white w/ neural structures dark¨ Compression or displacement of neural elements may be visualized

n Painful procedure

AP View (Owl)

Pedicles Vertebral Body

Transverse Process Spinous Process

The eyes should be open. Winking owls is typically s ign of pathology.Nose should be one piece. If separated in the middle, indicative of spina bifida occulta

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Spondylolysis

Spondylolisthesis

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Treatment Optionsn Evidence shows that most treatment

options have minimal impact on outcomes, are typically short term, and rarely change the longer term prognosis

n Goals of treatment include:¨pain relief¨ improvement of function¨reduced work absence¨prevention of chronicity.

Patient Educationn Education regarding their

diagnosis, which is important for self-management and reassurance

n Shared Decision Makingn Encouragement for Active

Lifestylen Health Seeking Behaviors

¨ Smoking Cessation¨ Exercise¨ Weight Loss

n Recognize & Evaluate for Psychosocial Risk Factors (yellow flags)¨ Inappropriate attitudes and beliefs about back

pain¨ Fear-avoidance behavior¨ Anxiety ¨ Depression¨ Workers’ compensation claim status¨ Litigation status¨ Socioeconomic factors¨ Malingering pain¨ Persistent request for narcotic medications

when inappropriate for treatmentn Biofeedback w/ Adaptive Coping

Behaviors¨ Distraction¨ Endurance

n Behavior Modification

Nonpharmacologicaln Exercise

¨ Physical Therapy¨ Aqua Therapy¨ IHEP (Walking, Stretching, Swimming, & Cycling)

n Chiropractic Care (aka spinal manipulation therapy)n Massagen Heat / Icen Tractionn Acupuncturen TENSn Back Supports

Pharmacological n Acetaminophenn NSAIDs (oral /

topical)n Weak Opioids

¨ Tramadol ¨ Tylenol #3

n Antidepressantsn Muscle Relaxantsn Antiepileptic /

Antineuropathicsn Steroids

Common Medications for LBP Managementn Traditional NSAIDs: etodolac (Lodine)

diclofenac (Voltaren)naproxen (Naprosyn, Aleve)

n Cyclooxygenas e- 2 (COX-2) inhibitor NSAID: celecoxib (Celebrex)

n Weak Opioids: tramadol (Ultram)acetaminophen/codeine (Tylenol #3)

n Muscle Relaxants: baclofen (Gablofen, Lioresal)tizanidine (Zanaflex)methocarbomal (Robaxin)cyclobenzaprine (Flexeril)

n Antiepileptics: gabapentin (Neurontin)topiramate (Topamax)

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Invasive Proceduresn Pain Injections

¨ Epidural Steroids¨ Facet Injections¨ Rhizotomy¨ Nerve Blocks¨ IDET

n Surgical Referral¨ Stenosis = lumbar laminectomy /

decompression¨ Radiculopathy = lumbar discectomy

n Probable causal factors¨ Increased tumor necrosis factor

αn Genetic Predisposition

¨ Changes in Interleukin 1, aggrecan, vitamin D receptors, collagen fiber genes (I, IX, XI), matrix metalloproteinase 3, and several proteins

n Obesity n Smoking

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