Spinal Pain

1. Spinal Pain Mark V. Boswell, MD, PhD ASIPP Board Review Course

2. ABMS Outline - Relevant to Spinal Pain XIII. Neck and Back Pain • Musculoskeletal • Arthritic • Rheumatologic • Postraumatic • Myofascial • Facets, ligaments,musculoskeletal • Other (? Pseudospinal)

3. Additional Categories XVIII. Neuropathic pain • Radiculopathy XX. Central Pain States • Spinal stenosis Note: these topics include diagnosis, related problems, therapy, psychiatric morbidity, etc

4. Focused Review • Spondylotic pain • Radiculopathy • Spinal stenosis • Infection • Tumors • Postraumatic • Rheumatologic • Pseudospinal pain

5. A Huge Differential Diagnosis for Spinal Pain

6. Differential Diagnosis: Age 20 years • Ankylosing spondylitis • Pyogenic sacroiliitis • Herpes zoster • Osteoid osteoma • Vertebral sarcoidosis • Rheumatoid arthritis • Osteoblastoma • Sickle cell disease • Scoliosis • Lyme disease

7. DDx. Age 30 yrs • Herniated nucleus pulposis • Musculoskeletal • Facet pain • Trochanteric bursitis • Sacroiliac pain • Fibromyalgia • Spondylolisthesis • Ovarian cancer • Pancreatitis • Intraspinal neoplasms

8. DDx. Age 40 years • Osteoarthritis • DISH (diffuse idiopathic skeletal hyperostosis) • Osteomyelitis/Disciitis • Paget’s • Chordoma • Sarcoma • Osteoporosis/fracture • Metastases

9. DDx. Age 50 and over • More metastases: • Lung cancer • Breast cancer • Prostate cancer • Spinal stenosis • Rheumatoid diseases • Abdominal aneurysm • Multiple myeloma

10. Low Back Pain and Musculoskeletal Disorders • Low Back Pain (any LBP) - 56% • Frequent or persistent LBP - 15% • Osteoarthritis - 12% • Fibromyalgia - 2% • Herniated disc (surgical) - 2% • Rheumatoid arthritis - 1% • Gout - 1%

11. Low Back Pain - Epidemiology Age-related prevalence • Children / adolescents - 12% • Adults - 15% • Elderly - 27%

12. Risk Factors for Low Back Pain • Gender • Weak association with female sex • Increased risk in pregnancy • Stronger relation to occupation than sex • Sciatica and disc operations more common in men • Height and weight • Possible increased risk with height • Weak correlation with weight

13. Other Risk Factors for LBP • Smoking • Inhibits metabolic processes in the disc • Weak relation with heavy smoking • Postural deformities • Poor correlation • History of back pain • Increased risk of recurrence • Previous surgery possible factor • Epidural fibrosis • Recurrent disc herniation • Spondylodiscitis • Arachnoiditis

14. Structural Basis of LBP • Largest amount of scientific data • Facet joints • Discogenic pain • Sacroiliac joint • Smallest amount of scientific data • Myofascial pain • Ligament pain • Trigger point pain

15. Psychiatric Disorders and LBP • Diagnosable mental disorder - 22% • Low Back Pain - 15 to 56% • Most common psychiatric disorders seen in patients with LBP • Depression (Major, Dysthymic, Bipolar,etc) • Generalized anxiety disorder • Somatization disorder • Personality disorder • Major depressive disorder - leading cause of disability in US and market economies worldwide

16. Waddell’s Signs • To aid in assessing functional (nonorganic) disorders • 5 signs: • Tenderness • Simulation (pressure or rotation) • Distraction • Regional disturbance (nonanatomic) • Overreaction • Significant if 3 or more positive Spine, 1980

17. Spondylolysis/Spondylolisthesis • Spondylos (Greek meaning vertebra) • Spondylolisthesis: one vertebra has slipped on adjacent vertebra • Spondylolysis: pars defect without slippage • 5 major types recognized • I: Dysplasia of L5-S1 facets • II: Isthmic - pars interarticularis (L5-S1) • III: Degenerative (not pars; typically L4-5) • IV:Traumatic • V: Pathologic

18. Spondylolisthesis • Grade I through IV; (25% slippage each) • Most common symptom is LBP • 50% note onset with injury • Leg pain due to nerve root irritation • Often patients are asymptomatic • Slippage more than 50% may require surgery if persistent pain and/or neurologic deficit • Posterolateral fusion

19. Pars Interarticularis Defect

20. Spondylosis • General term for degeneration due to osteoarthritis; may include ankylosis • Common cause of low back pain; multiple etiologies • Formerly known as degenerative disc disease • Cervical • Age related changes in disc • Secondary bony changes • Lumbosacral • Disc degeneration/ disc space narrowing • Facet degeneration • Ligamentous hypertrophy • Osteophytes

21. Facet (Zygapophysial) Joint Pain • Lumbar facet joints recognized as a source of pain since 1911 • Facet syndrome: lumbosacral pain with or without sciatica • Pain after rotary movement or twisting • Low back pain with radiation to thighs and buttocks • Poor clinical correlation with imaging or exam

22. Facet Joint Pain • Definitive diagnosis requires diagnostic blocks • Lumbosacral facet joints - 15 to 45% of cases of low back pain • Cervical facet joints - 54 to 67% of cases of neck pain • Common with “whiplash” • Validity, specificity and sensitivity of diagnostic facet joint nerve blocks are considered to be strong

23. Discogenic Pain • Concept of motion segment • Discs well innervated and can be source of pain • Discography: cardinal component is disc stimulation, provoking putatively painful disc • Concept of concordant pain • Concept of high intensity zone; posterior annular fissure • Evidence • Cervical and thoracic discography limited • Lumbar discography strong with precision techniques

24. Sacroiliac Joint Pain • Accepted source of low back and buttock pain • Prevalence of SI pain: 13 to 30% of cases of low back pain • May have radicular component - L5 pattern • Moderate evidence for efficacy of SI joint injections

25. Postlaminectomy Syndrome • Continued pain and disability following surgical intervention • Etiologies: • Canal stenosis • Internal disc disruption • Recurrent disc, fragment, etc • Fibrosis (epidural, intraneural) • Radiculopathy • Facet syndrome • Arachnoiditis

26. Radicular Syndromes

27. Definitions • Radiculopathy: disease of nerve roots • Radiculitis: inflammation of nerve roots • Pain, motor and sensory abnormalities • Plexopathy defined as involvement of 2 or more roots

28. Etiology of Radiculopathy • Cervical • Herniated disc and/or spondylosis - 69% • Herniated disc - 22% • Thoracic • Diabetes (most common cause) • Tumor • Scoliosis • Infection • Lumbar • Discogenic/spondylotic

29. Frequency of Cervical Root Compression by Herniated Disc

30. Upper Cervical Radiculopathy • Lesions of upper roots - C4, C5, C6 roots • Weakness: flexion forearm, abduction, internal and external rotation of arm • Deltoid • Biceps (reflex diminished or absent) • Triceps • Brachioradialis • Pectoralis • Supraspinatus, infraspinatus, subscapularis, teres major • Sensory loss incomplete: hypesthesia outer arm and forearm

31. Middle Cervical Radiculopathy • Injury to C7 root • Weakness: muscles supplied by radial nerve: • Triceps (blunted reflex) • Extensors of wrist and hand (except brachioradialis) • Sensory loss incomplete: dorsal surface of forearm and dorsal hand

32. Lower Cervical Radiculopathy • Injury to C8 and T1 roots • Weakness: muscles supplied by ulnar and median nerve • Flexor carpi ulnaris • Flexor digitorum • Interossei (atrophy 1st dorsal interosseus) • Thenar and hypothenar muscles • Sensory loss medial arm/forearm and ulnar hand

33. Cervical Root Syndromes Merritt’s Neurology; Low Back and Neck Pain

34. Frequency of Lumbosacral Root Compression in 97 patients { > 80% About 10% of herniations are lateral to canal and root sleeve (Hardy, 1982)

35. Lumbosacral Root Syndromes

36. MRI of Lumbar HNP

37. Polyradiculopathy • Disease of multiple roots • Etiology • Neoplastic infiltration • Lyme disease • Sarcoidosis • Diabetes • Asymmetrical and variable weakness • Patchy and less severe than weakness • Pain common but not invariable

38. Spinal Stenosis • Technically categorized as central pain in content outline • More correctly considered radiculopathy • Probably has ischemic etiology in classic case • Classic description: • Neurogenic claudication in upright position • Not necessary to walk to have pain • Stenotic canal (< 10 mm) causes root or cauda equina ischemia producing leg cramps

39. Spinal Stenosis • Compression syndromes of cauda equina and spinal cord • Single root or cauda equina • Abnormally narrow spinal canal • Acquired • Spondylosis • Arthritic proliferation • Ligamentous hypetrophy • Disc protrusion may exacerbate syndrome • Congenital (short pedicles)

40. Spinal Stenosis- MRI/Myelo

41. Don’t Forget Cervical Spinal Stenosis • May involve single root or cord • Cervical myelopathy • Muscles affected with weakness (looks like lower motor neuron disease) • Weakness, atrophy and fasciculations) • C5: Deltoid and biceps • C7: Triceps and wrist extensors • C8: Intrinsic muscles of hand • Cervical interlaminar injections are contraindicated with canal stenosis

42. Remember Differential Diagnoses Cervical root and cord problems may be confused with: • Supraspinatus tendinitis • Acromoclavicular pain • Rotator cuff tears • Cervical ribs • Must exclude sulcus neoplasms • C8-T1 lesions may cause Horner’s syndrome

43. Infections of the Spine

44. Osteomyelitis Uncommon cause of back pain 1:20,000 hospital admissions Gram positive cocci most frequent Urinary tract most common origin Hematogenous seeding (unless spine injection) Back pain is almost always present CRP, ESR best markers Discitis Osteomyelitis and/or hematogenous spread Surgical and diagnostic procedures Osteomyelitis/Discitis

45. Infections of the Spine Note: Incidence of spontaneous spine infection is 1:20,000 hospital admissions

46. Sources of Spine Infections Note: half of all sources may not be identified

47. Organisms Isolated

48. Cervical Osteomyelitis

49. Plain Xray Spondylitis

50. Axial MRI with Contrast Lumbar Discitis