What Else Could it Be?

Dr Mark Young FACSP

SpinePlus

Role in SpinePlus• To assess, dx and treat likely non-operative patients• Prescribe exercise rehabilitation, injection therapies

and advice• Fast track possible surgical patients to PL, and other

specialists if required• See emergency referrals

Goal – to provide best possible holistic and integrated care to patients with spinal disorder

Demography - Survey of 200 ReferralsOften had multiple pathologies

Patients 10 Reason for Referral

• 75% Lumbar

• 20% Cervical

• 5% Thoracic

• Final Dx of LxSp Referrals (150)

• 120 had clinically significant 10 Lx pathology

• 30 had 10 non Lx pathology (usually pelvic, occ limb or vascular)

Lumbar Conditions

Disc & Facet joint - degenerate or acute injury

Nerve – neuro-foraminal stenosis

Vertebral crush #

Discitis

Metastatic malignancy (2)

Ankylosing spondylitis (1)

Red Flags – not to be missed• Cauda Equina Syndrome (URGENT)

• Constitutional symptoms

• Immunosuppressed, recent infection, IVDU

• Age >50 (or <20)

• Phx of cancer, or osteoporosis

• Recent significant trauma

• Progressive neurology

• AM Stiffness, relief with exercise and NSAIDs/steroids (Spondyloarthropathy)

Non Lumbar Spine Conditions

• 20% - Why so many?

• Key Points• Both pelvic and Lx spine

pathology are common• Radiology of Lx spine often has

abnormality - ?conincidental• Lx spine conditions frequently refers to

pelvis and legs (disc, facet and nerve)• Some pelvic conditions aggravate LBP

Common Pelvic Conditionsthat mimic Lx Pathology

• Greater Trochanteric Bursitis

• SIJ degeneration

• Hip OA

• Hamstring tendinopathy

• Piriformis syndrome

Case 1

• 68 male – retired farmer

• 6 month Hx of LBP and rt buttock pain - only with walking (RtButtockP >or= LBP), no neuro Sx

• Reduced exercise tolerance (300 metres)

• Emotionally flat, gaining weight (aggravating glucose intolerance)

CT Lx Spine

• Mod/Sev Degenerate L4/5 facet joint arthritis

• Offered posterior spinal fusion

• Wanted second opinion.

Clinical Exam

• Normal gait (not antalgic, trendelenburg – ve, no foot drop)

• Lx flex & ext - mildly restricted (ext pain +)

• No neuro

• Slightly tender (+) central lower Lx spine. Mildly tender ant hip, not over lateral hip or pelvis

• Rt hip IR 0 degrees, buttock pain (+++)

Hip Xray

• Management –-refer to hip surgeon

• Why LBP?

• Key Points

• EXAMINE HIP (v. briefly)

• IR is first movement to be lost in hip pathology

Case 2

• 54 year old female recreational rower

• 6 mo hx of insidious onset of bilateral “sciatic pain” - mild LBP and mod hamstring pain

• Aggravated by sitting, Lx flexion and rowing

• Some leg weakness, no paraesthesia

MRI Lx Spine

• Seen by PL – no objective neural findings, several minor non-compressive disc bulges

• Suspected pelvic problem

Examination

• Mild Lx spine tenderness, good ROM Lx SP

• Mod bilat lower buttock/upper hamstring tenderness

• Sightly restricted SLR – due to hamstring tightness, -ve slump test, -ve Lasegues test,

• Weak hamstring curl and bridge

Pelvic MRI

• Bilateral hamstring origin degenerative tendinopathy with intra-substance tears

Management

• Modified activity

• Physiotherapy (prescribed hamstring conditioning program)

• Autologous blood injections

• ?Surgical opinion – if not improving after 3-6 months

Case 3

• 65 year old retired nurse –“nurses back”

• 6 month hx of insidious onset LBP, rt hip and thigh pain – esp at night, arising from chair, walking uphill

• Physio ++ with core stability exercises

• Referred CT Lx Spine

CT Scan

• Chronic L5/S1 broad based disc bulge with calcification

• No neuro-foraminalstenosis

Examination

• Overweight• Reasonable ROM Lx Sp – mild end range pain• No neuro signs• Mild lower Lx and buttock tenderness (R>L)• Normal Rt hip IR• Bilaterally tender over greater trochanters (R>>L)• Poor Rt abductor strength (Pos trendelenburg

sign & gait)• Weak on gluteus medius testing

MRI Right Hip

• Mild greater trochanteric bursitis

• Gluteus mediustendinopathy with intact tendons

Management

• Prescription of abductor conditioning rehab exercises

• CSI to 20 bursa (to permit enhanced exercise rehab)

• Advice, weight loss, general light exercise ++

• May need ABI/PRP/?ATI injections

• ?Surgical decompression – last resort (note full thickness tears need early surgical opinion as poor outcome)

Key Points

Lumbar spine radiological abnormalities are common - ?coincidental

Lx spine can refer to pelvis, but consider primary pelvic pathology if pelvic/leg pain > LBP

Do not miss RED FLAGS