The Spine

Neck
► Simple neck pain
► Neck pain with Radiculopathy
► Whiplash Injury – early mobilisation ?physio
referral
► Torticollis
► Cervical myelopathy – UMN legs, LMN arms
 http://www.youtube.com/watch?v=3PILgkVKlAg
► http://eng.mapofmedicine.com/evidence/
map/neck_pain1.html
 Acute low back pain - triage
► Simple mechanical, nerve root or red flag
► http://eng.mapofmedicine.com/evidence/map/
low_back_pain1.html
► Identify yellow flags early
► Refer root pain if not settling in 6w
 Record neuro signs – do they fit with MRI
 ?epidural ?discectomy – short/long term results
► Is
the leg pain radicular or referred - NSAIDs
not good for radicular pain
 Backs - neurology

Root Sensory loss Motor weakness Reflex

L4 Medial calf and Knee extension, Knee

ankle foot inversion

L5 Medial foot and Dorsiflexion foot None

hallux and hallux

S1 Outer foot and Plantar flexion foot Ankle

sole
 Rehab exercises?
► Few high quality trials
► Little evidence of effectiveness in acute LBP
► Some evidence that improves pain and
function in chronic LBP (particularly in
healthcare populations)
► Combats deconditioning
► Helps patients to feel in control and accept
that pain does not equal harm
 Causes of sciatica other than PLID
► Degeneration – lateral canal stenosis +/-
degenerate discs
► Spondylolisthesis – beware gymnasts,
runners, dancers
► Piriformis syndrome (overactive hip flexors,
underactive extensors/abductors, tight
adductors)
► Sacroiliac dysfunction??
 Spinal degeneration
► Cervical
– invariable by age 50
► Lumbar – 60% women and 80% men by age 50
 Disc dries out, splits and tears, loses height which..
 Puts extra strain on facet joints causing OA..
 Subluxation, sclerosis, osteophyte formation,
hypertrophy of capsule and ligamentum flavum…
 Lateral canal stenosis and sciatica (SLR)
 Vertebral lipping (osteophytes), facet and ligamentum
flavum hypertrophy may cause spinal stenosis
 Signs of L/S degeneration
► Loss of lordosis
► Reduced movement esp. flexion (Schober)
► Back or hip as source pain –
 Hip movement – rotation
 Trendelenberg gait and test
 Central canal spinal stenosis
► Neurogenic claudication – mechanism uncertain
► “numbness” “burning” “heaviness”
► Walk up better than down, Cycle better than walk
► Eased by bending forward
► Variable day to day
► Occasional bladder dysfunction
► May be Simian posture
► Signs relate to underlying degeneration, usually no
neurological signs
Chronic LBP – biopsychosocial model
► BIO
 Neuroplastic maladaption of the CNS and
peripheral nervous system leading to allodynia,
hyperalgesia and hyperpathia
 physical deconditioning (loss of muscle bulk,
strength & endurance, loss of aerobic fitness,
muscle imbalance and incoordination, and
altered proprioception) leads to dysfunction and
physical impairment
Chronic LBP – biopsychosocial model
► PSYCHO –
 chronic illness/pain behaviour (+ anger, anxiety,
depression & distress)

► SOCIAL –
 disability/handicap (mal)adaption to the chronic
sick role (chronic invalid)
 Yellow flags = psychosocial barriers to
recovery
► Total work loss due to LBP in past year
► Self rated health poor
► Heavy smoking
► Psychosocial distress
► Depressive symptoms
► Disproportionate illness behaviour
► Low job satisfaction
► Personal problems (alcohol, marital, financial)

► Adversarial medicolegal proceedings

 Yellow flags (2)
► Belief that pain and activity are harmful
► Sickness behaviours such as extended rest
► Social withdrawal
► Emotional problems such as low or negative mood,
depression, anxiety, stress
► Problems and/or dissatisfaction at work
► Problems with claims or compensation or time off
work
► Overprotective family; lack of support
► Inappropriate expectations of treatment, e.g. low
expectations of active participation in treatment
 Spondylolisthesis - degenerative
► Facet joint remodelling
► Very common e.g. 30-60% females >65yrs
► Spinal canal may narrow (napkin ring)
► Spinal claudication
► +/- lateral canal stenosis (radiculopathy)
► Decompression +/- fusion
 Spondylolisthesis - isthmic
► Spondylolysis – neural arch defect so..
► No spinal canal narrowing
► Common (5%), occurs age 6-16 then rarely
progresses.
► 90% low grade. Majority these asymptomatic. May
have activity related back pain +/- radiculopathy
► 10% high grade. May have no pain. Weakness.
Numbness. Deformity. Gait abnormality. Hamstring
tightness.
► Conservative management vs spinal fusion
 Adolescent scoliosis
► 30% have relative with scoliosis
► 4 per 1000 of which 1 will require surgery
► 80% rib hump on right
► May develop in infancy but more commonly
adolescence
► Baseline X-rays then all should be seen by scoliosis
specialist to assess progression
► Bracing is controversial but prevent progression
sometimes with view to surgery at end growth
spurt
► Surgery (based on Harrington rod) if >40-45
degrees from vertical.
 Imaging – X rays
► Making the best use of clinical radiology
services. http://mbur.nhs.uk/
► Suspected osteoporotic vertebral collapse
► ??spondylolisthesis
► ??sacroileitis
 Imaging MRI
► If considering referral for surgery
 Who should be referred to a spinal
surgeon?
► Acute radicular arm/leg pain >6w + not improving
 NB some improvement likely to imply eventual
resolution
 Pain and neurological symptoms in N root distribution
(MRI correlation)

► Refractive longer term (>3mths) radicular pain

significantly interfering with sleep/life/work

► Significant spinal claudication

Urgent surgical referral (same day).
► Cauda equina syndrome
► Severe motor weakness (ie loss plantar or
dorsiflexion)
► Progressive motor weakness (ie >1 N root)
► Myelopathy = long tract signs or signal
change on MRI at a stenotic level
 Urgent referral
► Red flags
 Who should not be referred?
► Referred pain
► Degenerative neck or back pain
► Non-specific neurological symptoms (ie
none radicular)
► If radicular pain significantly improving
► Residual numbness from previous episode
► If patient doesn’t want surgery
Mrs W 67yr housewife
 MRI result
Ventral listhesis L4 against L5 by approx 10mm
(Grade 1). Additional discal bulge in this segment
plus facet joint and flava ligament hypertrophy
resulting in severe spinal stenosis and compression
of thecal sac. The extra foraminal roots of L4 are
involved bilaterally so are the intraspinal roots of L5
on both sides. Segment L5/S1 unremarkable.
Moderate narrowing of the spinal canal also at L3/4
due to gross facet joint and flava ligmanet
hypertrophy. Upper L spine otherwise unremarkable
appearances.
Mr K 63yrs plasterer
Mr K MRI result
Referral letters
 References
► http://www.kspine.net/
► http://www.spine-health.com/
► Neurosurgicalreferral guidelines agreed by
3 Yorkshire and Humber centres 2009
► http://www.youtube.com/watch?
v=CVS1UfCfxlU