Spinal Pain

Mark V. Boswell, MD, PhD

ASIPP Board Review Course

ABMS Outline - Relevant to Spinal Pain

XIII. Neck and Back Pain Musculoskeletal Arthritic Rheumatologic Postraumatic Myofascial Facets, ligaments,musculoskeletal Other (? Pseudospinal)

Additional Categories

XVIII. Neuropathic pain RadiculopathyXX. Central Pain States Spinal stenosis

Note: these topics include diagnosis, related problems, therapy, psychiatric morbidity, etc

Focused Review

Spondylotic pain Radiculopathy Spinal stenosis Infection Tumors Postraumatic Rheumatologic Pseudospinal pain

A Huge Differential Diagnosis for Spinal Pain

Differential Diagnosis: Age 20 years

Ankylosing spondylitis Pyogenic sacroiliitis Herpes zoster Osteoid osteoma Vertebral sarcoidosis Rheumatoid arthritis Osteoblastoma Sickle cell disease Scoliosis Lyme disease

DDx. Age 30 yrs Herniated nucleus pulposis Musculoskeletal

Facet pain Trochanteric bursitis Sacroiliac pain Fibromyalgia

Spondylolisthesis Ovarian cancer Pancreatitis Intraspinal neoplasms

DDx. Age 40 years Osteoarthritis DISH (diffuse idiopathic skeletal

hyperostosis) Osteomyelitis/Disciitis Paget’s Chordoma Sarcoma Osteoporosis/fracture Metastases

DDx. Age 50 and over More metastases:

Lung cancer Breast cancer Prostate cancer

Spinal stenosis Rheumatoid diseases Abdominal aneurysm Multiple myeloma

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%

Low Back Pain - Epidemiology

Age-related prevalence Children / adolescents - 12% Adults - 15% Elderly - 27%

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

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

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

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

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 positiveSpine, 1980

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

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

Pars Interarticularis Defect

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

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

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

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

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

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

Radicular Syndromes

Definitions

Radiculopathy: disease of nerve rootsRadiculitis: inflammation of nerve

rootsPain, motor and sensory

abnormalities Plexopathy defined as involvement of 2

or more roots

Etiology of Radiculopathy Cervical

Herniated disc and/or spondylosis - 69% Herniated disc - 22%

Thoracic Diabetes (most common cause) Tumor Scoliosis Infection

Lumbar Discogenic/spondylotic

Frequency of Cervical Root Compression by Herniated Disc

Root Percent

C-5 2

C-6 19

C-7 69

C-8 10

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

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

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

Cervical Root Syndromes

Root Syndromes with Cervical Disc Herniation

Disc Space C4-5 C5-6 C6-7 C7-T1

Root affected C5 C6 C7 C8

Muscles affected

Deltoid, supraspinatus

Biceps,

brachioradialisTriceps, wrist

extensorsHand

intrinsics, interossei

Area of pain and sensory

loss

Shoulder, anterior arm,

radial forearm

Thumb Thumb, middle fingers

4th, 5th fingers

Reflex affected

Biceps Biceps, triceps

Triceps Triceps

Merritt’s Neurology; Low Back and Neck Pain

Frequency of Lumbosacral Root Compression in 97 patients

Root Percent

L2-3 1

L3-4 9

L4-5 45

L5-S1 42

About 10% of herniations are lateral to canal and root sleeve(Hardy, 1982)

{> 80%

Lumbosacral Root Syndromes

Root Syndromes with Lumbar Disc HerniationDisc Space L3-4 L4-5 L5-S1

Root Affected L4 L5 S-1

Muscles Affected

Quadriceps Peroneal, anterior tibial, extensor hallucis longus

Gluteus max, gastroc, plantar

flexors toes

Area of Pain and Sensory Loss

Anterior thigh, medial shin

Big toe, dorsum foot

Lateral foot, small toe

Reflex Affected Knee jerk Posterior tibial

(medial hamstring)Ankle jerk

Straight Leg Raising

May not increase pain

Aggravates pain

Aggravates pain

MRI of Lumbar HNP

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

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

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)

Spinal Stenosis- MRI/Myelo

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

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

Infections of the Spine

Osteomyelitis/DiscitisOsteomyelitis

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

Infections of the Spine

Cervical 8%

Cervical thoracic <1%

Thoracic 35%

Thoracolumar 8%

Lumbar 42%

Lumbosacral 7%

Sacral <1%

Note: Incidence of spontaneous spine infection is 1:20,000 hospital admissions

Sources of Spine InfectionsGenitourinary tract 46%

Skin 19%

Respiratory tract 14%

Spinal surgery 9%

Bowel 4%

IV drug use 3%

Dental 2%

Bacterial endocarditis 1%

Note: half of all sources may not be identified

Organisms IsolatedGram positive aerobic cocci 72%

Staphylococcus aureus 63%

Staphylococcus coagulase neg 2%

Streptococcal species 7%

Gram negative aerobic bacilli 24%

Escherichia coli 16%

Proteus species 5%

Pseudomonas species 1%

Klebsiella species 1%

Other 1%

Anaerobic bacteria (eg, bacteroides) 3%

Fungi (eg, candida); Mycobacteria <1%

Cervical Osteomyelitis

Plain Xray Spondylitis

Axial MRI with Contrast Lumbar Discitis

Tumors of the Spine

Benign Osteoid osteoma Osteoblastoma

Malignant Myeloma Osteosarcoma Chondrosarcoma Skeletal metastases

Malignancy

75% of cases in patients over age 50 yrs Previous history of malignancy - 30% Less than 1% of all patients with back pain Etiology

2/3 are metastatic Myeloma most common primary malignancy Nonspinal malignancy: pancreatic, renal,

retroperitoneal lymphadenopathy

Metastatic Tumors Most common tissues of origin in

decreasing order: Lung Breast Prostate Kidney Unknown site Sarcoma Lymphoma Colon Thyroid Melanoma

Sites of Metastatic Involvement

Cervical Spine 6 - 19%

Thoracic Spine 49% Lumbar spine 46%

Signs, Symptoms and Diagnosis

Constant back pain unrelieved by position change

Night pain; Weight loss ESR good screening test; elevated in 80% Serum immunoelectrophoresis (myeloma) PSA > 10 ng/ml MRI; CT scan; plain films positive in 65% Bone scan positive in osteoblastic tumors

Postraumatic Spine Pain

C Spine Alignment

Examples of C-Spine InjuriesFlexion Injury Anterior subluxation

Wedge compression

Bilateral interfacetal dislocation - “locked facets”

Flexion teardrop fracture

Flexion-rotation Unilateral facet dislocation

Vertical compression Jefferson burst fracture of atlas

Burst fracture

Hyperextension Dislocation

Atlas arch fractures

Traumatic spondylolisthesis (hangman’s C2)

Others Dens fracture

Note: all are unstable to highly unstable

Cervical Locked Facet

Flexion-Rotation Subluxation

Note: may be stable unless fracture or articular mass

Jefferson Fracture

CT Jefferson Fracture

Hangman’s Fracture

Dens Fracture

Dens Fracture

C6 C7 view important

Compression Fracture

Rheumatoid Arthritis

RA 1-3% of population; Male: female 1:3 RA: inflammation synovial joints,

osteoporosis Majority of patients have cervical spine

involvement Pain, headaches and arm numbness Decreased motion of neck Prominence of C2 process Lumbar spine rarely involved May have sacroiliac disease

Cervical Spine Involvement in RA

Atlantoaxial subluxation Anterior most common (46% of patients

postmortem) Insufficiency of transverse ligament or

odontoid erosions or fracture Unstable cervical spine

Vertical subluxation (cranial settling) Subaxial subluxation C3-7

Ankylosing Spondylitis Seronegative spondyloarthopathy Disease of axial skeleton and sacroiliac

joints 1-2% of population; HLA B-27 Enthesitis: inflammation at insertion of

tendon, ligament, capsule or fascia on bone

chondritis osteitis Ankylosis of joints and ossification of

ligaments

Extra-articular Manifestions of AS

Ocular Iritis 25 - 40% of patients

Cardiovascular 10% of patients Fibrosing lesion of aortic valve Cardiac arrhythmias Proximal aortitis

Extra-articular Manifestions of AS

Pulmonary Restrictive disease Kyphosis Late pulmonary fibrosis

Renal Microscopic hematuria Amyloidosis IgA nephropathy

Polymyalgia Rheumatica Hip, neck and shoulder girdle pain Onset over 50 yrs Male: Female 1:3 Upper and lower back Elevated ESR Temporal arteritis in 40 to 50% Treatment: prednisone, methotrexate

Pseudospinal Pain

Back and/or leg pain as the presenting symptom systemic visceral vascular neurologic disorder

Pseudospinal conditions are common

Abdominal Aortic Aneurysm 1-4% of population over 50 yrs 1-2% of all male deaths over 65 yr Abominal pain with radiation to hips

and thighs 12% have back pain Diagnosis: ultrasound or CT Repair if > 6 cm or increasing > 1

cm/yr

Endometriosis Reproductive age Pelvic pain Abdominal pain Back pain 25-31% Diagnosis: laparoscopy Treatment: oral contraceptives, danazol

(testosterone analogue)

Piriformis syndrome

Myofascial v. entrapment syndrome

Simulates L5/S1 radiculopathy Entrapment of sciatic nerve at

piriformis muscle;fibrous band 6% of cases of sciatica

Piriformis syndrome Pseudosciatica - SLR usually negative Freiburg’s sign: internal rotation of hip

(stretches piriformis muscle) Resisted abduction and external

rotation may produce pain EMG: normal proximal; may be slight

change distal Imaging studies equivocal Treatment: stretch; injections, release

Other Disorders Fibromyalgia - 2% Trochanteric bursitis - 25% ? Pelvic inflammatory disease Prostatitis

Lifetime prevalence 50% Nephrolithiasis 3% Pancreatitis and pancreatic cancer

Midepigastric pain radiating through to back

References Manchikanti, et al. Low Back Pain. Various chapters.

ASIPP Publishing, 2002. Borenstein, et al. Low Back Pain, 3rd Edition, Various

Chapters, Saunders, 2004 Rowland, L. Merritt’s Neurology, 10th Edition, various

chapters, Lippincott Williams and Wilkins, 2000. Manchikanti, et al. Evidence-based practice guidelines

for interventional techniques in the management of chronic spinal pain. Pain Physician. 2003: 6:3-81

Tintinalli, et al. Emergency Medicine. A Comprehensive Guide. Various chapters. McGraw-Hill, 2000.