Revision Low Back Pain
Revision – Low back pain
Contents
Congenital (occurred prior to birth)
Spina Bifida Occulta
Spondylolisthesis
Facet direction anomalies, L/S anomalies
Scoliosis
Klipperfeil
Acquired - Traumatic
Muscle tear
Ligament injury
Fractures e.g. Vertebral
Facet Dysfunction
Herniated Disc
Acquired - Infective
Osteomyelitis
Tuberculosis TB
Discitis
Acquired - Inflammatory
Ankylosing Spondylitis
Rheumatoid disease of joints RA
Acquired - Neoplastic
Bone Metastasis
Osteosarcoma, Fibrosarcoma, Chondrosarcoma
Acquired - Degenerative
Osteoarthritis, Spondylosis, Spondyloarthrosis
Disc lesion
Facet problems
Lumbar spine stenosis
Acquired - Metabolic
Osteoporosis
Osteomalacia / Rickets
Acquired - Endocrine
Cushings
Acquired - Idiopathic
Padget’s disease
Scheuermann’s disease aka Osteochondrosis or Osteochondritis
Piriformis syndrome
Congenital / AcquiredSpina Bifida / Traumatic
- Muscle tear
- Ligament damage
- Joint strain
- Fracture
- Disc injury
Block vertebrae / Infective
- Osteomyelitis
- TB
Lumbarisation / Inflammatory
- AS
- RA
Sacralisation / Neoplastic
Scoliosis / Degenerative
- OA
- Disc
Metabolic
- Osteoporosis
- Osteomalacia
Klipperfeil / Endocrine
- Cushings
Facet Anomalies / Idiopathic
- Padgets
- Schermanns
Low riding, High riding L5 / Psychogenic
Visceral
Vascular
Gynae
Renal
Red Flags
- Unexplained weight loss
- Hxx of malignancy
- Infection
- Symptoms unrelated to movement
- Cauda Equina
Anatomy:
Congenital (occurred prior to birth)
Spina Bifida OccultaDefinition / Failure to unite/develop the posterior arch leaving the spinal canal exposed reducing the attachment site of ligaments and muscles
Who gets it / Estimated that 25% of LBP population
Folic acid defect in diet prior to conception and during pregnancy (folic acid is found in breakfast cereal, baked beans, green leafy veg, peas and chickpeas, oranges)
Suspected link to LDL gene error
Taking epilepsy and bipolar medication whilst pregnant (valproate, carbamazepine, lamotrigine)
Signs / Dimple in low back
Hairy patch in low back
Pigmented area in low back
Haemangioma
Symptoms / Low back ache
Stiff low back
Poor gait
Medical Tests / X-ray
Complications / Congenital neoplasm
Mid-line spur splitting the spinal canal
Tightened shortened filum terminale causing a low lying spinal cord
Spina cord can be tethered which can cause paralysis as the child grows
Poor bladder control
Carvo varus – heel inverted, increased arch, clawed toes and adducted foot
What can we do / Advise on diet prior to and during pregnancy
Advise to discuss medications with the doctor prior to and during pregnancy
Avoid HVT of the low l.sp considering the possible instability in that area
Spondylolisthesis
Definition / Anterior movement of the vertebral body with or without Spondylolytic (a fracture of the pars interarticularis in the lumbar spine)
Retro lythesis is a backward movement of the vertebral body
Who gets it / Young: spondylolytic spondylolisthesis (commonly L5/S1 with step at L4/5)
Elderly: non-spondylotytic spondylolithesis (commonly L3/4 with a step at L3/4) due to degenerative changes
Predisposed by: congenital anomaly, bony weakness, fibrosis union only, increased lumbar lordosis, increased functional demands, growth spurts with participation in active sports, pregnancy, visceralptosis anda loss of abdominal tone.
Symptoms / Odd gait
Acute back pain eased by rest, worse on standing, agg by increased hamstring tone
Groin strains, Hamstring strains that won’t resolve
C/T pain or H/A
Wide ranging from no symptoms (incidental finding, esp. in children) to severe back & leg pain with nerve damage esp. on hyperextension of the back. Beware of Cauda Equina syndrome
Young child 6-7 YOA – acute back pain, agg by weight bearing and eased by bed rest. Poor range of l.sp flexion
Older child – excessive sports >24 hours per week with hard landings and falls, stress from hyperlordotic activities
Young adult – hxx of contact sports with an injury that is failing to resolve.
Signs / Palpable step
Reduced flexion
Increased tension in hamstrings
tests you can do / Vibration test with tuning form to establish whether there is a #
Palpate for a palpable step
medical tests / X-Ray (most visible from an oblique view), looking for the scotty dog with an increased neck length (degenerative) or a collar (fracture) at worst decapitated!
CT scan
Grading according to the amount of slippage (grade 1 <25%, 2 = 25-50% 3 = 51-75% 4 = 67-100% etc)
medical treatments (and side effects) / Wide ranging from observation to surgical stabilization of the spine depending on the age of the patient, type of slip and symptoms experienced.
contraindications to specific osteopathic techniques / Hyperextension, HVT, strong articulatory techniques esp. in extension can all cause further slippage
Facet direction anomalies, L/S anomalies
Sacralisation / A developmental anomaly where the 5th lumbar vertebra fuses with the sacral vertebra
Lumbarisation / A developmental anomaly where the 1st sacral vertebra is not fused to the rest of the sacrum. It acts like an additional lumbar vertebra
Block vertebrae / Occur with improper segmentalisation
Hemi vertebrae / Wedge shaped vertebrae and can cause an angle in the spine. Most common in the mid thorax especially T8. Can cause narrowing of the spinal canal and instability of the spine.
Possible cause is a lack of blood supply
Scoliosis
Definition / Type / Pathology / Examples
Congenital / Abnormal spinal development / hemi vertebra
Idiopathic
Can be early onset before 10yoa or late onset 10-18yoa / unknown / Adolescent idiopathic scoliosis
Neuromuscular / Abnormal forces acting on the spine / Cerebral palsy
Spina bifida
Mm dystrophies
Spinal cord injuries
Secondary/
compensatory / Curve develops secondary to other process / Glove puppet - LLD.
String puppet - Asymmetry in cranial base-
Antalgic postures-trunk will tilt markedly
Who gets it / Idiopathic-2.5% of population effected. F:M 9:1
Presents at juvenile and adolescent ages.
Symptoms / Increased incidence of back ache.
Can be symptomless.
Signs / Deformity. -Spinal curve, rib hump, LLD, protruding scapulae.
Idiopathic structural-
Initial lateral curve with compensatory curves above/below.
Pt is side bent and rotated ipsilaterally, until centre line of weight bearing moves away from spinal axis, the rotation is reversed to compensate; ribs are thrown back on the convex side, increasing deformity.
Once the S/B is ipsilateral and ROT is contralateral then this is a Structural Scoliosis
Tests you can do / Measure leg length
Check standing to seated posture.
Bony landmarks
Forward flexion –high side more apparent.
Medical tests / Standing x rays- show and monitor progress of curve
MRI to exclude any ass. cord abnormality.
Measurement of lateral curve-‘cob angle’ on a/p x-ray
Measurement of the rib angle- done with pt flexed at 90look at the angle of the back away from horizontal.
Medical treatments (and side effects) / In mild to moderate idiopathic curves-bracing (Milwaukee)
Congenital most neuromuscular and severe idiopathic = Surgery –harrington rods spinal fusion, stabilisation correction
contraindications to specific osteopathic techniques / Severe thoracic curves have systemic implications to the pulmonary and cardiovascular systems.
Scoliosis association uk advised osteopathy can help with pain, we CANNOT prevent curvatures progressing.
Klipperfeil
Definition / A congenital condition where there is fusion of two or more cervical vertebrae
Who gets it / ?developmental anomaly
?foetal alcohol syndrome
?vascular compromise
Symptoms / Reduced range of motion of the cervical spine
Renal anomalies
Cardiovascular anomalies
Signs / Short neck, Low hairline,
Restricted range of motion in the cervical spine
Also associated with other congenital anomalies e.g. Spengel shoulder
Medical Tests / X-ray
Medical ttt
Contraindications / Cervical instability
Cardiovascular compromise
Spinal cord stenosis
Acquired - Traumatic
Muscle tearDefinition / A stretching or tearing of a muscle or tendon as a result of an overstretch
Classed as:
- Grade 1 - there is very minor damage to the muscle fibres
- Grade 2 - there is a partial tear of the muscle fibres
- Grade 3 - there is a complete tear of the muscle fibres
Who gets it / Anyone from a traumatic onset
Symptoms / Local pain, stiffness, bruising,
- Grade 1 –sore, able to continue with activity
- Grade 2 –lots of pain, swelling, bruising
- Grade 3 –lots of pain, swelling, bruising, no muscle function
Signs / Visible signs of damage (swelling or bruising)
Agg: Recruitment of the muscle. Stretch to the muscle. Flexion and S/B away from the damaged side. Usually all spinal movements are affected
NAF: Passively shortening the muscle, EXT
Treatment /
- Rest for 48-72 hours
- Ice
- Compression
- Elevation
Ligament injury
Definition / A stretching or tearing of a ligament
- GRADE 1 - There is damage to a few collagen fibres, producing a local inflammatory response.
- GRADE 2 - There is damage to a more extensive number of collagen fibres.
- GRADE 3 - The damage to collagen fibres is such that there is a complete rupture of the ligament.
Who gets it / Anyone from a traumatic onset
Symptoms /
- Grade 1 - This is characterised by pain over the affected ligament.
- Grade 2 - This produces a more marked inflammatory response characterised by intense pain and joint effusion (swelling).
- Grade 3 - This produces intense pain, joint effusion and marked joint instability. Surgery may be necessary to restore joint stability.
Signs / Increased ligament laxity
Muscular spasm
Agg: end of range stretch to the damaged part of the ligament
NAF: active resisted muscle test
Fractures e.g. Vertebral
Definition / Disruption in the continuity of bone tissue
Complete = complete separation of bone e.g.Spondylytic Spondylolythesis
Incomplete = some bone fragments still intact
Stress # = Incomplete # from unusual or repetitive strain
Crush # = Collapse of a vertebra due to trauma, osteoporosis or other bone degenerative conditions
Greenstick # = only in children. Bone is less brittle and can therefore bow without complete disruption of the bones cortex
Simple # = Skin remains intact
Compound # = Skin is broken
Who gets it / Anyone
Symptoms / Local pain. Muscle guarding.
Stress # = pain after exx, then pain during and after exx, then continual pain and night pain
Signs / Case Hxx v important.
Crush # may cause loss in height.
Tests you can do / Tuning fork – use large tuning fork, place over area. This will cause extreme pain in the case of a fracture. However, false negatives can occur!
Stress # = Hopping on one leg (the affected leg) should elicit pain.
Medical tests / X – ray. Some #s may not show on X – ray until osteoblastic activity occurs i.e. a few days post trauma.
Medical treatments (and side effects) / NSAIDs (SE = GI problems i.e. stomach ulcers with prolonged use)
Immobilisation i.e. with a cast (SE = mm wasting and poor venous drainage)
Surgery – commonly offered with hip #s to decrease the risk of DVT’s and pulmonary embolism. Otherwise offered when bony remodelling is required. (SE = infection)
Contraindications to specific osteopathic techniques / Pain may limit ttt. Crush # indicates weakness of the vertebral body and therefore, avoid HVT.
Complications = Compartment syndrome
Necrosis i.e. Scaphoid bone
Facet Dysfunction
Facet direction in the L.sp = parasaggital enabling FLEX, EXT, S/B with limited ROT
Definition / Synovitis/haemarthrosis (acute sprain) – transient LBP, strain/nipping to the capsule causes effusion which is relieved 2-3 days due to reduced segmental health, fibrogen deposited into the joint causing Intracapsular adhesions
Stiffness
Painful entrapment
Mechanical block
Chronic facet dysfunction
Who gets it / Synovitis/haemarthrosis (acute sprain) –. Onset with a sudden movement, initially with sharp localised pain. Can radiate to the buttock and iliac crest.
Painful entrapment – an acute pain, leads to postural deviation away from the painful side immediately following injury.
Prolonged standing with a lordotic L.sp can stress the living bone and cause remodelling, enlargement and realignment of the facets to reduce stress and redistribute it
Symptoms / Synovitis/haemarthrosis (acute sprain) - Initially sharp localised pain, Onset with a sudden movement
Painful entrapment – an acute pain when trying to resume normal alignment. The pain may migrate up the back 1 day later with painful muscular guarding
Signs / Synovitis/haemarthrosis (acute sprain) - Can be palpated in the c.sp
Painful entrapment – an acute pain with an Antalgic posture
Prognosis / Synovitis/haemarthrosis (acute sprain) – 2 weeks
Herniated Disc
Definition / Extrusion of the nucleus pulposus through a tear in the annulus fibrosus.
Can cause pressure on the nerve route.
Who gets it / Commonly young adults (30-50 yoa) at the L/S, then L4/5, the L3/4
Vunerable to failure of the posterior ligamentous system due to the influence on the pre-stressing mechanisms of facet and disc.
Sustained flexion puts a distraction force on the posterior disc and failure can occur at the posterior annulus or PLL. If repeated and sustained this can begin the process of discal degeneration. Desk slumping, Congenital anomalies, Acquired anomalies, Trauma
High riding L5 (body in line with iliac crest)
Low riding L5 (L4 on the inter iliac line)
Sacralisation
Lumbarisation
Spina bifida
Block vertebrae
Symptoms (Can vary) / Commonly back pain with very limited mvt (inability to straighten up fully).
Pain may worsen with flexion, coughing and straining, sitting
If a nerve route is irritated symptoms of NRI or NRC will be present i.e. pain into the limb, P+N, numbness or weakness (“I can’t pick my foot up properly, it drags along the floor”).
Onset is gradual
Occasionally symptoms of cauda equine – saddle anaesthesia, urinary retention, and faecal incontinence.
Pathophysiology / Stress to outer tissues which lose their integrity and become stretched
Results in poor nutrition with compromised pumping mechanisms
Can cause a loss of proprioceptive function increasing the vunerability to damage
Muscles are recruited to provide the lost support which fatigue and this stress eventually reaches the disc
Prolapse normally posteriolateral
Prognosis / 1 – 3 months
Signs / There may be a loss of the lumbar lordosis, a protective scoliosis and mm guarding.
Flexion may relieve the leg pain
Lateral shift away from the herniation
Side bend away can relieve symptoms
SLRT with pain radiating below the knee in a lancinating line. Possible not below the knee... not found in Grieve Chapter 6!
With NR involvement there may be reduced or absent reflexes, reduced or absent sensitivity to touch (light/sharp), and weakness in a specific dermatome/myotome.
Tests you can do / Neurological tests including reflexes, power, light touch, and pin prick. SLR to test neural tethering. If crossed SLR is positive high chance of disc involvement. Quadrant tests and slump tests can be used.
Medical tests / MRI will show the disc.
X-ray may show a narrowed joint space.
Medical treatments (and side effects) / NSAIDs and analgesics (SE = GI upsets, constipation, stomach ulcers). Oral steroids or local epidural injection (SE = osteoporosis, or iatrogenic Cushings if long term use).
96% recover within 6 months without surgical intervention (webmd.com). Indicators for surgery are objective weakness and other neuro findings, limitations to daily activity, worsening leg pain for at least 1 month despite prescribed NSAIDs and analgesics, confirmation of disc herniation by MRI.
Discectomy - surgical removal of herniated disc that presses on a nerve root or the spinal cord. – 10% have persistent symptoms post surgery, especially those with severe neuro deficit before hand. 10% have a reoccurrence some time after the surgery. There is a risk of infection. Most are successful.
Fusion – Bone graft is used to fuse 2 or more vertebra together to completely prevent spinal mvt. Disc may be removed and replaced – fairly old-fashioned method. SE = altered spinal mechanics, potential for injury elsewhere from increased demand..
Contraindications to specific osteopathic techniques / Discs are generally injured in flexion when lifting something heavy or via torsion injuries. Therefore it is best to avoid reinforced flexion and rotational mvts in treatment. This means that HVT’s at the affected segment are contraindicated.
Acquired - Infective
OsteomyelitisDefinition / Osteomyelitis is an infection of a bone usually Bacterial
e.g. Staphylococcus Aureus, MRSA
who gets it / Recent #, Artificial Hip, Prosthesis, Recent Surgery,
Immune compromised i.e. AIDS, Chemo-TTT, Diabetes
( sensation), Steroids use, previous Osteomyelitis Hxx.
Symptoms /
- Pain and tenderness over an area of bone
- A lump may develop over a bone, very tender
- Redness of overlying skin
- Feeling generally unwell with fever (high temperature) as the infection spreads
Signs /
- Redness, Swelling, Pain around the fracture site, tender lump, Pus may exit from wound over fracture site
OMT tests / None
medical tests / Early Stages: Blood Test/Bone Biopsy
Later Stages: X Ray/Surgery
Medical ttt (and S/E) / Antibiotic TTT (within 3-5 days of the start of infection)
OMT and contraindications / RED FLAG (fever, infection)
Avoid infected area (gloves) on inspection
Tuberculosis TB
Definition / Tuberculosis (TB) is a bacterial infection (mycobacterium tuberculosis). It is spread through inhaling tiny droplets of saliva from the coughs or sneezes of an infected person.
TB mainly affects the lungs. However, the infection can spread to many parts of the body, including the bones (e.g. spine), organs and nervous system
TB develops slowly in the body. You may not experience any symptoms for many months or even years after being infected.
Latent TB is where the body is able to wall off the infection
Who gets it / Immune compromised e.g. HIV infection
Non vaccinated
Living in an area
Poor diet & lifestyle
Diabetics
People on steroids
It is suspected that 1 in 8 adults have latent TB
Symptoms / persistent cough
weight loss
night sweats, fever
In skeletal TB - bone pain, curving of the affected bone or joint, loss of movement or feeling in the affected bone or joint, weakened bone that may fracture easily
Signs / Enlarged lymph nodes
Temperature
Tests / Respiratory exam
Spinal exam
Medical tests / X-ray, quite difficult to diagnose
Sputum test
Medical ttt / Preventative – BCG vaccination if a negative mantoux test
A combination of antibiotics (the Edinburgh method?)
OMT / Can cause fibrosis in the lungs
Can cause
Discitis
Definition / An infection that affects the intevetebral disc space.
Who gets it / Usually under 8 YOA
Post surgery
Symptoms / Severe Pain in low back or area of surgery
Signs / Children may be arching their back
Severe pain
May refuse to walk
Tests
Medical tests / MRI but X-ray and CT may indicate
Biopsy
Medical ttt / Antibiotics
Pain medication
Brace
If developed into an abscess then this will be drained
OMT / Recommend keeping moving within pain limits to encourage fluid movement in the area
Acquired - Inflammatory
Ankylosing SpondylitisDefinition / A chronic inflammatory condition affecting the spine and SIJs
Who gets it / Young adults 15-40 More Men (9:1)
Women tend to get a more peripheral joint involvement
Thought to be a genetic predisposition with HLA B27
Thought to be some environmental triggers
Pathophys / Inflammation occurs at enthesis,
Bone erodes
Healing with fibrous tissue
Ossification of fibrous tissue results in ankylosis
Reduced ROM
Repetitive cycle.
Symptoms / Stiffening worse in AM (lingers for 3 hours) and after rest. Stiff in more than one or two spinal joints.
Symptoms improve with exx
Insidious onset of LBP and discomfort. Intermittent LBA lasts days/weeks
Early involvement of SIJ
Stiffness especially in T/L
Pain my radiate to buttock and posterior thighs, rarely below knees
Other features: Ethesitis (plantar fasciitis, Chostochondritis, Achilles tendinitis and attachment sites at the pelvis)
Non articular symptoms: Fever, Malaise, Iritis, Cardiac involvement, Neuro involvement, Lung fibrosis due to t.sp fusion
Signs / Reduced L.sp lordosis
Maybe muscle spasm
Reduced mobility in all directions
Tenderness at local enthuses
Pain on sacral springing
One or more painful swollen joints
Medical tests / X-ray: Romanus lesion where syndesmophytes form at the insertion of the outer fibres of the annulus, Calcification of the interspinous and supraspinous ligaments leading to a bamboo spine
Increased ESR with inflammation
HLS-B27
Medical ttt / NSAID and Analgesia
OMT / Mobilise
Advice on EXX, Posture, Avoid prolonged activity
Acquired inflammatory cont...