Spine Concepts: Low Back Pain
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Courtesy: Prof Nabil Ebraheim,
University of Toledo, Ohio, USA
Dr. Ebraheim educational animated video illustrates spine concepts associated the lower back – lumbar spine.
• Acute low back pain: or low back pain with sciatica:
– where the pain radiates to the leg and foot, both conditions are treated conservatively for at least 6 weeks by physiotherapy, anti-inflammatory and limited activity, even if there is a big disc in the MRI.
– 90% of the patients will resolve the symptoms in 1 month.
– Smoking, depression, vibration will increase the incidence of low back pain.
– Intra-discal pressure will change with position, the lowest pressure is when the patient is supine, the highest pressure is when the patient is sitting leaning forward and holding weight.
– If the patient comes with a low back pain and a history of cancer, you need to get an x-ray & MRI, especially if the pain is at rest at night.
– In case of renal tumor, you will need to do arteriography and do embolization to the spine lesion.
– The spine is a common place for metastatic tumors, the metastasis occur in the vertebral body and goes to the pedicle.
– Infection will occur in the disc space, ESR & CRP will be elevated, 50% of the patients will have fever, & less than 50% will have increased WBC count.
– Get blood culture, its positive in 24% of the cases.
– Get MRI and give antibiotics.
– In the case of epidural abscess, we’ll do surgery.
– Osteoporotic fracture: start with wrist then spine, then hip.
– After 1 year of treatment with medications you decrease the incidence of vertebral fracture by 60%, and after 2 years decrease by 40%.
– Get x-rays if there is red flags only: older patient, patient with history of cancer, infection is suspected, trauma, osteoporotic fracture due to steroid use.
– Ankylosing spondylitis: it starts at the SI joint, get HLA-B27, you find marginal syndesmophytes with diffuse ossification of the disc space without large osteophyte formation. This is different from the DISH (diffuse idiopathic skeletal ossification) in diabetic patients where you get HbA1c and the syndesmophytes are nonmarginal & they have larger osteophytes.
– Disc herniation: disc is an elastic soft cushion between the vertebrae of the spine.
• Conditions with confusing names:
– Spondylolysis: this is an anatomical defect or break of the pars interarticularis that occurs usually in the 5th lumbar vertebra in about 5% of the population & hyperextension makes it worse, on oblique x-ray: you see “scotty dog sign”
– Spondylolisthesis: this is a slippage of the vertebral body over the other, occurs usually at L5-S1 in the pediatric population, L4- L5 in female adults, if there is a large slip it will continue to slip, & if you have a dysplastic slip it will continue to progress.
– Spondylitis: it is an inflammation of the vertebrae, like ankylosing spondylitis or TB.
– Spondylosis: is vertebral arthritis, it narrows the neural foramen, pinch the nerve roots and causes radiculopathy, in the cervical spine, compression of the spinal cord from arthritis can lead to myelopathy which means gait disturbance broad base shuffling gait, upper extremity clumsiness and weakness, upper neuron signs may be present such as Huffman’s sign and Babinski reflex.
– Coexisting cervical myelopathy can occur in lumbar stenosis.
– Lumbar spinal stenosis: there are 2 types of lumbar spinal stenosis:
1- Central stenosis: will give neurological claudication
2- Lateral recess stenosis: will give the radicular symptoms.
It occurs because of a hypertrophy of the facet and the ligamentum flavum and spine arthritis, it will cause compression of the nerve root, this is the one where the back pain is better, because it open the foramen.
History is the key for making a diagnosis of lumbar stenosis.
If it occur in the intervertebral foramen then it is called the neuroforaminal stenosis.
Look for other reasons such as metastatic tumor or vascular conditions, always examine the pulses.
– Neurogenic and vascular claudication may coexist, walking is bad for both conditions, sitting relive the symptoms in both conditions, stopping and standing still is good for the vascular claudication, but still cause symptoms for lumbar stenosis, the bicycle relieve the lumbar stenosis but aggravate the vascular.
– In the vascular the pain starts within the calf and leg, in neurogenic it starts proximally then spreads distally.
Postural changes of the spine will make the neurogenic claudication worse, but doesn’t affect the vascular claudication.
Vascular claudication will be affected by muscle movement or function such as walking or riding a bicycle.
In neurogenic claudication leaning over while riding the bicycle will relieve the symptoms in the same way as the shopping cart sign.
Treatment for the lumbar stenosis: for the central canal stenosis: decompression by laminectomy, lateral recess stenosis: medial facectectomy, add fusion for instability or if more than 50% of the facets are removed.
The risk of pseudoarthrosis is 500% with smoking.