1. health and fitness
2. disease
3. arthritis

LUMBAR STRAIN: Back to the Basics
1
Gaetano P. Monteleone, Jr., M.D.
Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
I.
Epidemiology
Low back pain (LBP) is the second most common symptom that causes patients to seek
medical attention in the outpatient setting. Approximately 70% of adults have an episode of LBP
as a result of work or play. Hundreds of millions of dollars are spent in the diagnosis and
treatment of this array of conditions.
II.
Anatomy
A.
Bones
1. Vertebral body
2. Vertebral arch- 2
pedicles, 2 lamina, 2 pars
interarticularis.
3. Cartilaginous endplateshyaline cartilage separates
annulus and nucleus from
vertebral body.
B. Soft tissue
1. Disc- made up of
peripheral annulus fibrosus
(fibrous) and the central
nucleus pulposus
(gelatinous). A "slipped
disc" really represents a
leakage of the NP into the
foramen. A subsequent
inflammatory reaction may
irritate the nerve root.
2. Ligaments- the anterior
and posterior longitudinal
ligaments run the length of
the vertebral bodies and
resist flexion and
extension. The interspinous ligament attaches two adjacent spinous processes. The
supraspinous ligament attaches all spinous processes.
LBP 12/20/05
LUMBAR STRAIN: Back to the Basics
2
Gaetano P. Monteleone, Jr., M.D.
Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
3. Muscles- the large thoracolumbar fascia represents a grouping of fascia and several
muscles. Paraspinal muscle group and abdominal musculature are other important
anatomical support for the back. Remember that muscle groups for the anterior and
posterior legs are instrumental in lumbar biomechanics.
III.
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LBP 12/20/05
History
Location- consider if dermatomal Vs nondermatomal pattern
? Radiation- radiation into the leg is common in many nonradicular syndromes. The term
sciatica is used frequently in clinical practice and the literature. A widely agreed on
definition of sciatica is unavailable. Perhaps the term radiculopathy is more clinically
accurate and should reflect radiation of pain below the knee. The implication is that nerve
root irritation exists. The most common causes of pain radiating into the distal lower
extremity are HNP and lumbar stenosis.
Mechanism- lifting, torsional forces, car accidents.
Duration- 85% of all back pain will resolve in 2 weeks. (depends on end point measured)
Associated symptoms- paresthesias, paresis, fever, weight loss, urinary/bowel
incontinence. Paresthesias may be circumferential or dermatomal. Sensitivity and
specificity of paresthesias (indicating HNP) are low, 75% and 15%, respectively. True
radicular sxs indicate possibility of nerve impingement or irritation (herniated nucleus
pulposus [HNP] or OA). Associated fevers, weight loss and anorexia may indicate
infection or cancer. Bowel or bladder abnormalities, especially urinary retention, may
indicate cauda equina syndrome, a surgical emergency.
Initial treatment- has the patient used ice/heat, specific medication, done any exercises?
PMHx- other musculoskeletal disorders, GI abnormalities, dermatologic disorders,
cancer.
This part of the Hx is important for a number of reasons. Peptic ulcer
disease or reflux disease in a patient will affect medication choices. In addition, patients
with dermatologic or GI disturbances coupled with musculoskeletal problems may have a
rheumatologic condition. In patients over 50 years old with back pain and a prior Hx of
cancer, consider bony mets.
PSHx- has the patient had prior surgery? If so, gadolinium-enhanced MRI is more useful
than unenhanced MRI in differentiating scar tissue from infection, Ca and HNP.
3
LUMBAR STRAIN: Back to the Basics
Gaetano P. Monteleone, Jr., M.D.
Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
Estimated accuracy of medical history in diagnosis of spine disease causing low back
problems
References
Deyo and Diehl
Waldvogel and
Vasey
Unpublished
data[a]
Disease to
be
detected
Medical history red flags
Cancer
Age >= 50
Previous cancer history
Unexplained weight loss
Failure to improve with 1 month of
therapy
Bed rest no relief
Duration of pain > 1 month
Age > 50 or history of cancer or
unexplained weight loss or failure of
conservative therapy
IV.
LBP 12/20/05
0.31
0.90
> 0.90
0.50
0.46
0.81
1.00
0.60
Spinal
osteomyelitis
Intravenous drug abuse, UTI, or skin
infection
0.40
NA
Compressi
on fracture
Age >= 50
Age >= 70
Trauma
Corticosteroid use
0.84
0.22
0.30
0.06
0.61
0.96
0.85
0.995
Sciatica
0.95
0.88
Pseudoclaudication
Age >= 50
Positive responses 4 out of 5
Age at onset <= 40
Pain not relieved in supine position
Morning back stiffness
Duration of pain &gte;3 months
0.60
0.90 [b]
0.23
1.00
0.80
0.64
0.17
NA
0.70
0.82
0.07
0.49
0.59
0.54
Deyo and Tsui- Herniated
wu, Spangfort
disc
Turner, Ersek,
Spinal
Herron, et al.
stenosis
Gran
True-positive True-negative
rate
rate
(sensitivity)
(specificity)
0.77
0.71
0.31
0.98
0.15
0.94
Ankylosing
spondylitis
Physical Exam
A. Inspection- deformities, scoliosis, erythema, ecchymosis, gait, heel and toe walking
B. Palpation- point tenderness (bony and soft tissue)
4
LUMBAR STRAIN: Back to the Basics
Gaetano P. Monteleone, Jr., M.D.
Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
C. Range of Motion- measure forward flexion in inches from the floor
N.B. Signs of slow deliberate gait, decreased lumbar lordosis and limited range of motion
are important. However, they have low diagnostic utility, since many causes of acute low
back pain will manifest these signs.
D. Neurovascular Assessment (most important is L4-S1): individually test heel and toe
walking. Minor asymmetry is common. A positive test should show marked asymmetry.
Nerve Root
Sensory
Reflex
Motor
L4
Anterolateral thigh
Medial ankle
Patellar
Tibialis anterior
L5
Posterolateral thigh
Dorsum of ankle
? Posterior tibialis
Extensor hallucis
longus
S1
Lateral ankle
Achilles
Peroneus
Cross innervation is common and may result in misinterpretation. For screening
purposes, extensor hallucis longus (L5) is most important. Remember that differentiating a
peripheral nerve abnormality is necessary. Posterior tibialis and gluteus medius muscles are
innervated by L5 nerve root, but not the peripheral peroneal nerve. Note: these tests have only
moderate sensitivity and specificity for nerve root
irritation.
E. Special Tests
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Straight leg raise (SLR) +
ankle dorsiflexion: pt
supine, raise leg to 30-60°;
+ test is pain that radiates
into the calf. Also, crossed
SLR = SLR in unaffected
limb exacerbates radicular
pain in affected limb.
LBP 12/20/05
5
LUMBAR STRAIN: Back to the Basics
Gaetano P. Monteleone, Jr., M.D.
Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
¾
Seated straight leg raise: With pt seated, examiner passively extends the
knee; + test produces radicular pain.
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Modified SLR (? Lasegue's test): hip flexed to 90°, knee flexed to 90°,
this should not cause pain if HNP; examiner then extends the knee until
nerve root is stretched. Pain with knee extension may indicate nerve root
irritation demonstrated with HNP or impingement with OA.
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Bowstring sign: SLR until pain, then flex the knee. This should
reduce/extinguish pain if nerve root irritation.
All of these variants on the SLR theme should be considered sensitive, but not specific
for nerve root irritation. Reports of sensitivity and specificity range from 96-97% and 1015%, respectively. To date, studies have not been very precise in defining a positive test
(which makes reproducibility of these tests difficult). Also note that reports on crossed SLR
improves specificity (at the expense of sensitivity) to 85-95% (sensitivity from 20-30%).
Test
Sensitivity (%)
Specificity (%)
PV+ (%)
SLR (ipsilateral)
96-97
10-15
70
Crossed SLR
20-30
85-95
80
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¾
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FABER test = Flexion ABduction External Rotation of the hip: this
position may cause pain in SI joint pathology.
Pelvic rock test- the examiner grasps B/L ASIS anterior pelvis and
pushes posteriorly. Pain at the SI joint indicates SI joint pathology.
One-leg extension (or Arabesque) test: pt stands on one leg with back in
extension (examiner supports); + test of pain may indicate spondylolysis.
Hamstring flexibility- pt supine, hip and knees both at 90° flexion;
examiner attempts to passively straighten leg. Measure from line
perpendicular to floor.
Leg length evaluation- measure from ASIS to medial malleolus (in cm).
Estimated accuracy of physical examination for lumbar disc herniation among patients
with sciatica
LBP 12/20/05
6
LUMBAR STRAIN: Back to the Basics
Gaetano P. Monteleone, Jr., M.D.
Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
Truenegative
rate
(specificity)
Comments
References
Test
Truepositive rate
(sensitivity)
Hakelius and Hindmarsh;
Kosteljanetz, Espersen,
Halaburt, et al.
Ipsilateral
SLR
0.80
0.40
Positive result: leg pain
at < 60 degrees
Hakelius and Hindmarsh;
Spangfort
Crossed SLR
0.25
0.90
Positive result:
reproduction of
contralateral pain
0.35
0.70
HNP usually at L4-L5
(80 degrees)
Ankle
dorsiflexion
weakness
Hakelius and Hindmarsh;
Great toe
Kortelainen, Puranen, Koivisto,
extensor
et al.
weakness
Hakelius and Hindmarsh;
Spangfort
0.50
0.70
Impaired
ankle reflex
0.50
0.60
Kortelainen, Puranen, Koivisto,
Sensory loss
et al.; Espersen, Halaburt, et al.
0.50
0.50
0.50
NA
0.06
0.95
< 0.01
0.99
Hakelius and Hindmarsh;
Spangfort
Aronson and Dunsmore
Hakelius and Hindmarsh
Hakelius and Hindmarsh
Patellar reflex
Ankle plantar
flexion
weakness
Quadriceps
weakness
HNP usually at L5-S1
(60 degrees) or L4-L5
(30 degrees)
HNP usually at L5-S1;
absent reflex increases
specificity
Area of loss poor
predictor of HNP level
For upper lumbar HNP
only
Note: Sensitivity and specificity were calculated by Deyo, Rainville, and Kent. Values represent
rounded averages where multiple references were available. All results are from surgical case
series. HNP = herniated nucleus pulposous. SLR = straight leg raising.
V.
Radiology
A. Views- my L-spine series includes AP and lateral views. If the patient is younger and
spondylolysis/listhesis is a consideration, bilateral oblique views will be diagnostic. Consider
standing films if a question of spondylolisthesis or OA. It has been demonstrated that obtaining
AP and lateral films in the standing position may increase the amount of slip (of vertebral body
L5 on S1) from 25-40%. This will have great impact grading of spondylolisthesis. OA is readily
LBP 12/20/05
LUMBAR STRAIN: Back to the Basics
7
Gaetano P. Monteleone, Jr., M.D.
Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
seen on AP and lateral films. Degenerative changes on plain films are common in older
individuals but have demonstrated a poor correlation with clinical symptoms.
Plain films may also assess for instability. While still being debated, current consensus is
that > 3mm of difference between two vertebrae on lateral x-ray may indicate instability.
A number of authors suggest obtaining x-rays if sx duration > 6 weeks, h/o trauma, sxs of
tumor (constitutional sx, wt loss).
B. MRI- very useful for visualizing an HNP, tumor, infection in symptomatic individuals.
A number of studies have demonstrated a high incidence (up to 30%) of MRI changes consistent
with disc protrusion in asymptomatic pts! Must correlate findings with clinical presentation.
Does the Add gadolinium if prior history of surgery. This enhancement will differentiate scar
tissue from cancer and HNP.
C. CT-myelogram- adjunctive test. Some authors recommend this test (myelogram
followed by CT scan) for symptoms of neurogenic claudication. Their rationale is based on
better visualization of bone and hypertrophic spurs, assessment of anatomy of pedicles
(important in planning of operative reconstruction).
D. Electromyogram (EMG): probably overused as a diagnostic tool in LBP. We tend to
rely more on historical and physical factors for diagnosis. In addition, this test does not usually
change treatment plans, but may add to pt morbidity. This test is more useful when the diagnosis
is in question or if seriously considering a peripheral neuropathy.
VI.
LBP 12/20/05
Management
A. RICE (Rest, Ice, Compression, Elevation)
B. Pharmacologic intervention
¾
Anti-inflammatory meds (NSAID's) are common first line agents. Ibuprofen is
just as effective as the newer, fancier NSAID's. If one class does not work,
consider switch to another class of anti-inflammatory med. Remember to allow
up to 7-10 days for full anti-inflammatory effect. In patients with Hx of
PUD/GERD, before the release of COX-2 inhibitors we would often consider
addition of a prostaglandin analog to protect the stomach (misoprostol [Cytotec]
100-200 µg PO TID). Arthrotec provides a combination of diclofenac and
cytotec. Dosages are 50 and 75 mg diclofenac/0.2 mg misoprostol. These are
expensive and can cause diarrhea, but still should be considered, especially if
COX-2 is contraindicated.
¾
COX-2 selective NSAID's minimal effects on COX-1 receptors, and thus minimal
gastrointestinal and clotting effects. In some studies celicoxib (Celebrex) has
caused no more adverse GI effects than placebo. Efficacy for inflammation has
been comparable to other NSAID's. Caution with PMHx of CAD.
LUMBAR STRAIN: Back to the Basics
8
Gaetano P. Monteleone, Jr., M.D.
Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
¾
¾
¾
¾
¾
Acetaminophen- demonstrated to be as efficacious as an anti-inflammatory dose
of ibuprofen in relief of OA-type pain.
Opiates- consider narcotic use in acute, severe pain (3-4 days). There is no
support in the literature for their use after this. They may also interfere with
attempts at rehabilitation phase.
Muscle relaxers- efficacy has been questioned repeatedly. I tend to use sparingly.
Again, they may interfere with rehabilitation. Multiple authors suggest, "Treat the
pain and the muscle spasm will rescind."
Antidepressants- multiple studies demonstrate analgesic effect of antidepressants,
especially tricyclics. Can also assist with sleep disturbances. Usual dose is
generally less than that required for treatment of depression.
Neuroleptics- examples include neurontin (900-1800mg/D ÷ TID), tegretol (4001200mg/D ÷ BID-QID) and Lyrica (150mg BID). Adjunct therapy for nerve root
irritation/peripheral nerve pain. Efficacy in these clinical situations to be
determined.
C. Rehabilitation
1. Home exercise program- Three types:
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William's flexion exercises
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McKenzie's extension exercises
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Hamstring flexibility exercises
2. Physical Therapy- may help with modalities (cryotherapy, ultrasound, electric
stimulation, iontophoresis, massage). Will also lay-on hands and spend more time
educating patients on proper lifting techniques, sitting techniques, etc.
3. Consider heel lifts or orthotics (shoe inserts) if biomechanical abnormalities.
D. Epidural injections
¾
Frequently used by pain control centers. First reports of their use in 1901
(cocaine). Efficacy controversial. Balagué (1996) analyzed available
randomized controlled trials regarding the efficacy of these techniques.
Half of the studies demonstrated efficacy better than control and half did
not. He recommends no more than three injections at 1 to 2 week
intervals.
VI.
Specific Disorders
A. Lumbar strain- pull or overuse of the lumbar musculature.
Hx- may be acute pull, or insidious onset. Pain localized to the low back, buttocks and
into posterior thigh. Usually not true radicular pain.
LBP 12/20/05
LUMBAR STRAIN: Back to the Basics
9
Gaetano P. Monteleone, Jr., M.D.
Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
PE- pain to palpation of paraspinal musculature. Negative straight leg raise. Normal L1S1 exam. Negative FABER and pelvic rock tests, indicating no SI joint involvement. May
have poor hamstring flexibility.
Dx- History and physical exam. X-rays if associated with trauma, or pain not improving
despite adequate treatment.
Natural History- 85% of lumbar strain improves within 2 weeks. The majority of the
remainder will improve within the next 2 weeks.
Rx- RICE, NSAID’s, exercises to stretch and strengthen the lumbar musculature,
improve flexibility of the leg musculature.
B. Spondylolysis and Spondylolisthesis
Definition: Spondylo = vertebra, lysis = breakdown)defect in the pars interarticularis. Spondylolisthesis
(listhesis = slippage) involves displacement of
vertebral body anteriorly upon its subjacent member.
Most common L5-S1; less common L4-5.
Incidence: incidence in the general population 2-5%.
Incidence in the athletic population increases to 11%
in sports with a lot of extension maneuvers
(gymnastics, volleyball, tennis, diving, wrestling,
football and weight lifting). Spondy is usually
bilateral (80%). Peak age 15 yrs old.
Etiology: Physical forces- shear forces on the normal
lumbar lordosis are increased in extension and further
accentuated in combined extension and lateral
flexion. Genetic factors also play a role in the development of spondy. There is a high
incidence in identical twins and first-degree relatives (25-70%).
Classification of Spondylolisthesis:
Isthmian (spondylolytic)- most common cause
of listhesis. Up to 50% of total cases
Dysplastic (congenital)-20% of all cases. Failure
of development of superior facets
Degenerative- degeneration of superior facets or
disc. Major cause of spinal stenosis
Traumatic- disruption of posterior elements of
neural arch other than pars (pedicles or lamina)
Pathologic- osteoporosis, RA, tumor, infection
LBP 12/20/05
Grade of Spondylolisthesis
I- up to 25% L5 vertebral body on sacrum
II- 25-50%
III-50-75%
IV- > 75%
LUMBAR STRAIN: Back to the Basics
10
Gaetano P. Monteleone, Jr., M.D.
Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
Hx- Most are asymptomatic. Of those symptomatic, back pain is most common
complaint. May radiate to buttocks or thigh, but rarely do pts experience true radicular
sxs. Pain often worse with activity (extension/lateral side-bending maneuvers).
PE- Tender to palpation of paraspinal musculature. May appreciate a step-off in listhesis
> 50% (grade III or more). Hamstring tightness or spasm commonly present.
Occasionally a gait abnormality will be demonstrated (usually pelvic waddle).
X-ray¾
Plain films usually diagnostic. Obtain standing obliques. Visualize the "Scotty
dog," it will have a fracture through its neck with spondy. This is the defect in the
pars interarticularis. The lateral view will demonstrate grade of slip. If this slip is
severe L5 will be situated anterior to the sacral promontory. On the standing AP
x-ray an "inverted Napoleon's hat" sign will be apparent. Clinically, this puts the
cauda equina at risk for compromise. Standing films may increase amount of slip
up to 24-40% more than non-standing films.
¾
Triple phase bone scan with technetium may assist in the acuity of the defect.
Just because a defect is seen on x-ray does not mean it is the cause of symptoms.
This test is better for younger patients. In pts with OA, less helpful 2° false
positives. Also not recommended in asymptomatic pts or with sxs > 1 yr.
Rx- treatment for most cases of spondylolysis is nonsurgical. The consideration of a back
brace has been discussed in the literature. Bracing occurs if bone scan is positive. The
most common type of brace used is the TLSO (thoracolumbar sacral orthosis). Its
purpose is to limit amount of motion at the lumbar spine, though its effectiveness has
been questioned. Reported duration of bracing is varied. Most commonly cited is 6
months in TLSO (23 hrs/day), 6 months wean from brace (decrease to 18 hrs, then 12 hrs,
then 6 hrs during the 6 months). Others favor 3 months in/ 3 months wean. In most cases
of spondylolysis, the above regimen coupled with supportive care will produce
asymptomatic patient. Serial x-rays (q 6-12 months?) may be necessary to document any
listhesis- especially in adolescence during growth spurt. One growth plates close, further
slippage is unlikely. Return to sport when full, painless range of motion, good strength,
good aerobic capacity.
LBP 12/20/05
LUMBAR STRAIN: Back to the Basics
11
Gaetano P. Monteleone, Jr., M.D.
Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
Indications for Surgery
Risk Factors for Slip Progression
Progression of slippage
Neuro deficit
Refractory pain
Persistent gait abnormality
Slip angle > 50° in skeletally immature
Age- listhesis progresses mainly in 10-15 yrs
Sex- female more likely to progress
Symptoms- with recurrent sxs, more likely to slip
Grade of slip- grades III, IV more likely to
progress
Class of listhesis- dysplastic (congenital)
C. Herniated nucleus pulposus (HNP)
1. Leakage of nucleus pulposus into the foramina or spinal canal. Most common
direction of leakage is posterolateral. Most common site is L5-S1, followed by L4L5(95% of clinically relevant HNP at these two levels). Average age = 42 yrs
(range 18-68).
Classified as:
¾
Bulge- usually not clinically
relevant.
¾
Protrusion- extends into foramen or
spinal canal
¾
Extrusion- extends further
¾
Sequestration- free fragments
Hx- Back pain, leg pain, or both. Frequently
back pain develops first, and then leg pain
begins as back pain recedes. Worsened with
forward flexion, prolonged standing/sitting
and Valsalva maneuvers. The prevalence of
HNP in acute low back pain is low, ~ 1%.
PE- + SLR/crossed SLR/seated SLR. +
motor weakness and decreased reflexes to the corresponding affected nerve root.
Dx- x-rays- disc space narrowing is not a useful guide to assess for possible HNP.
X-rays most useful in r/o other disorders. MRI may demonstrate HNP well (but
clinical correlation required). Remember; up to 30% of asymptomatic pts will
demonstrate disc protrusion on MRI! (60% of ASx pts will have a disc bulge!!).
Natural history- most studies indicate that nonsurgical management = surgical
management at one year. There is some indication that the further the NP
protrudes/extrudes the more likely that the body's scavenger system
(phagocytosis, etc.) will eradicate the NP. This leads to the eventual resorption of
LBP 12/20/05
LUMBAR STRAIN: Back to the Basics
12
Gaetano P. Monteleone, Jr., M.D.
Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
this material. Note: Symptomatic improvement occurs prior to this resorption.
Rx- usually nonsurgical. NSAID's, antidepressants, relative rest and
cryotherapy are initial treatment options. After acute sxs improve, aggressive
P.T. plus modalities will help. Mobilization, strengthening (usually McKenzie's
extension exercises) and flexibility are key to sx improvement.
ƒ Antidepressants: Most supportive data on TCA’s (elavil) and symptom
improvement. Dose is usually less than needed for Rx of depression.
Consider SSRI’s as well, though less support in literature.
ƒ Also consider Neurontin or Lyrica. Average dose of neurontin is 9001800 mg a day (divided TID-QID). Average dose of Lyrica is 150mg BID.
Most common side effect is somnolence.
ƒ Epidural injections with local anesthetics or steroids have been
suggested. Over twenty studies have looked at the efficacy of epidural
injections. Half demonstrate improvement, half do not.
Surgical treatment for progressive neurologic deficits, intractable pain, lack of
expected response to P.T./rehab regimen of adequate length (8-12 weeks). Pts
with predominantly calf pain seem to respond better to surgery than those with
predominantly back pain.
D. Piriformis syndrome
The piriformis syndrome is
somewhat controversial in that its diagnosis
and treatment have not been well defined in
the literature. This syndrome may represent
up to 5% of the cases of patients with
"sciatic" type pain. Often considered a
diagnosis of exclusion. ? Is this the same as
wallet neuritis?
Anatomy- the piriformis muscle is
located underneath the gluteal
musculature, but on top of the
sciatic nerve. If this muscle is
hypertrophied or in spasm, it may
impinge upon the sciatic nerve and
produce Hx and PE factors
consistent with irritated nerve root.
Hx and PE- Variable. Sitting may exacerbate pain, especially after long trips. In
addition, there may be pain with resisted external rotation or passive internal
LBP 12/20/05
LUMBAR STRAIN: Back to the Basics
13
Gaetano P. Monteleone, Jr., M.D.
Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
rotation of the hip (AKA Freiberg's sign). There usually is pain to deep palpation
of the sciatic notch. While sensory changes may occur in this syndrome, motor
weakness is typically not present.
Rx- Treatment is as above. In this case I would consider muscle relaxers in acute
pain. Also, rigorous flexibility program specifically addressing the piriformis
will help. Physical therapy modalities (include stretch and spray techniques) has
been described. Some authors suggest piriformis muscle injection with local
anesthetic. Surgery is reserved for recalcitrant cases that do not improve with
nonsurgical treatment.
E. Osteoarthritis (OA)
Hx- lack of trauma, insidious onset of pain, worse upon awakening but improves
within 30-60 minutes.
PE- nonspecific; may demonstrate radicular signs if encroachment on nerve by
spurs, etc. Usually with inflexibility, + limb length discrepancy.
X-rays- classic spur formation that may encroach upon the foramina or spinal
canal. Recall that the nerve root only occupies 25-33% of the foraminal
opening. X-ray findings do not correlate well with intensity of symptoms.
Rx- as above. Consider heel lifts for leg length discrepancy and vigorous
flexibility program. Also, consider facet joint injections.
F. Vertebral Compression Fracture(Osteoporosis)
Hx- Acute vs subacute onset of localized back pain at site of fx. Most common
levels for compression fx T8-L3.
PE- nonspecific. Point tender paraspinal musculature and midline. Neuro exam
usually normal.
Dx- plain xray usually diagnostic. Consider CT if questions of bony fragments
encroaching on spinal canal/cord.
Rx- treat underlying osteoporosis! Calcium + vitamin D. Otherwise treatment as
in section A. For some patients, vertebroplasty (fluoroscopic injection of cement)
or kyphoplasty (injection of a balloon into vertebral body) may be helpful.
G. Sacroiliac sprain
Some authors question the existence of this clinical entity. Probably more
common in pts with rheumatologic disorder (the sacroiliac joint possesses a
synovial membrane). The SI joint does move ~ 5-7o.
Hx and PE findings are very variable. Usually lacks true radicular components.
Lacks neuro deficits. Some authors attribute positive FABER and pelvic rock tests
LBP 12/20/05
LUMBAR STRAIN: Back to the Basics
14
Gaetano P. Monteleone, Jr., M.D.
Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
to SI joint pathology.
Rx- as mentioned above. Joint mobilization techniques by physical therapists may
also give sx relief.
H. Cauda Equina Syndrome
A surgical urgency. Compromise of the cauda equina- the horses tail or whip.
Associated with HNP or grade 4 spondylolisthesis.
Hx and PE- Defined as progressive neurologic deficits with bowel or bladder
dysfunction- mostly urinary retention. In fact, the sensitivity of urinary retention
as a diagnostic “test” for cauda equina syndrome has such a high sensitivity that a
negative “test” virtually rules out the possibility of cauda equina.
Rx- surgical decompression and stabilization.
LBP 12/20/05
LUMBAR STRAIN: Back to the Basics
15
Gaetano P. Monteleone, Jr., M.D.
Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
REFERENCES
Andersson GB, Deyo RA. History and physical exam in patients with herniated lumbar discs. Spine. 21:10S-18S,
1996.
Assendelft WJ, Bouter LM, Knipschild PG. Complications of spinal manipulation- a comprehensive review of the
literature. J of Fam Pract. 42(5):475-80, 1996.
Balagué F. Injections and low back pain: outcome and randomized controlled trials. Bulletin- Hosp for Joint
Diseases. 55(4): 185-90, 1996.
Boden SD, Davis OD, Dina TS, et al. Abnormal magnetic resonance scans of the lumbar spine in asymptomatic
subjects. JBJS. 72A: 403-8, 1990.
Boos N, Rieder R, Schade V, et al. The diagnostic accuracy of magnetic resonance imaging, workplace perception,
and psychosocial factors in identifying symptomatic disc herniations. Spine. 20:2613-25, 1995.
Congeni J, McCulloch J, Swanson K. Lumbar spondylolysis- a study of natural progression in athletes. AJSM.
25(2): 248-53, 1997.
Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain. JAMA.
268(6):760-65, 1992.
Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people
without back pain. NEJM. 331:69-73, 1994.
Muschik M, Hahnel H, Robinson PN, et al. Competitive sports and the progression of spondylolisthesis. J Pediatric
Orthop. 16: 364-9, 1996.
Parziale JR, Hudgins TH, Fishman, LM. Piriformis syndrome. Am J Orthop. 25(12): 819-23, 1996.
Powell FC, Hanigan WC, Olivero WC. Neurosugery. A risk/benefit analysis of spinal manipulation therapy for relief
of lumbar or cervical pain. 33(1):73-9, 1993.
Shekelle PG. Spine update- spine manipulation. Spine. 19(7):858-61, 1994.
Suarez-Almazor ME, Belseck E, Russell AS, et al. Use of lumbar radiographs for the early diagnosis of low back
pain. JAMA. 277(22):1782-6, 1997.
Vucetic N, Svensson. Physical signs in lumbar disc hernia. Clin Orthop Rel Res. 333: 192-201, 1996.
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