Evaluation and Triage of Lumbar Spine Patients

1
Evaluation and Triage of Lumbar Spine Patients

• Alan M. Scarrow, M.D., J.D.
• Section of Neurosurgery
• St. Johns Hospital

2
Lumbar Spine Disease

• 75-80 of all people have back pain at some time
  in their life
• Annual prevalence of back pain 15-45
• 5th most common cause of admission to the
  hospital
• 3rd most common surgical procedure

3
Lumbar Spine Disease

• Low back pain is second to upper respiratory
  problems as a reason for visits to a physician
• In the U.S., back pain is the most common cause
  of activity limitation in people younger than 45
  years
• Cost of low back pain to industry estimated
  35-75 billion

4
Evaluation of Lumbar Spine Disease

• Where to start?
• What do we know?
• What to do?
• Who to consult?
• What will they do?

5
What we know v. what we think we know

• answering very
• Topic ?s correctly confident
• SI joint pain 4.4 32.2
• Lumbar stenosis 12.6 28.6
• Leg length differences 42.0 27.0
• Fibromyalgia 57.1 35.5
• Myofascial pain (piri) 68.7 8.5
• J Am Geriatr Soc 541772-1777 2006

6
Evaluation of Lumbar Spine Disease

• From the top
• Patient History
• Location of pain
• Duration of pain
• Character/quality of pain
• Weakness
• Numbness

7
Evaluation of Lumbar Spine Disease

• Psychological factors anxiety, depression,
  somatization symptoms, stressful
  responsibilities, job dissatisfaction, mental
  stress at work, negative body image, weakness in
  ego functioning (prospective predictors of
  developing back pain)
• Activities that affect pain (e.g. leaning forward
  in spinal stenosis, sitting down, coughing,
  sneezing, Valsalva for herniated discs)

• Bowel, bladder or sexual dysfunction
• Prior or current treatments including medication
• Smoking (smokers complain of more severe symptoms
  and have less improvement postsurgically)
• Obesity (obese patients more likely to suffer
  radicular pain or neurologic symptoms and carry
  more comorbidities)
• Diabetes (may need neurophysiology testing)

8
Evaluation of Lumbar Spine Disease

• Physical Exam
• Strength
• Sensation
• Reflexes
• Range of Motion
• Palpation

9
Evaluation of Lumbar Spine Disease

• Strength exam
• L3 - iliopsoas muscle (hip flexion), adductor
  longus (hip adduction)
• L4 - quadriceps femoris (knee extension),
  tibialis anterior (dorsiflexion and inversion)

• L5 - gluteus medius/minimus (thigh abduction and
  medial rotation), extensor hallicus longus (big
  toe extension), peroneus longus and brevis
  (plantar flexion and eversion)
• S1 - gluteus maximus (thigh abduction), biceps
  femoris (hip extension), gastrocnemius (plantar
  flexion)

10
Evaluation of Lumbar Spine DiseaseLower
extremity sensation
11
Evaluation of Lumbar Spine Disease

• Reflexes
• L3 - iliopsoas reflex (meaningful?)
• L4 - knee jerk
• L5 - extensor hallicus reflex (meaningful?)
• S1 - ankle jerk
• Babinski - in adults, UMN lesion from motor strip
  to lower spinal cord

12
Evaluation of Lumbar Spine Disease

• Range of Motion
• Straight leg raise - most sensitive for sciatic
  pain syndromes
• Pain in contralateral leg with straight leg raise
  is most specific for sciatic pain syndromes
• Lumbar flexion/extension (lumbar stenosis worse
  with extension, better with flexion)

13
Evaluation of Lumbar Spine Disease

• ROM to rule out other causes of back/leg pain
  internal and external hip rotation
• Palpation over spine, SI joint, pelvis and hip

14
Evaluation of Lumbar Spine Disease

• Clinical impression
• lumbar disc herniation pain, paresthesias,
  weakness, depressed DTRs in an anatomic
  distribution (i.e. down lower extremity)
• lumbar stenosis diagnosis made mainly by
  history low back/leg pain with walking or
  standing improved by sitting or lying down (not
  just standing still) no severe cramping in calf
  no trophic changes in skin a.k.a. neurogenic
  claudication

15
Evaluation of Lumbar Spine Disease

• Clinical impression
• lumbar instability pain with motion improved
  with lying down gt5 mm motion on
  flexion/extension x-rays indicates unstable
  motion segment look for defects in neural arch
  (lamina, pedicle, pars interarticularis) 30 of
  patients with degenerative spondylolisthesis
  (subluxation) will have progressive slippage
• compression fracture acute to subacute onset of
  pain, pain to palpation /- history of
  trauma/cancer
• musculoskeletal pain with active but not passive
  motion point tenderness over joint /- history
  of trauma

16
Evaluation of Lumbar Spine Disease

• If clinical suspicion high for soft tissue
  (i.e. muscle, tendon, joint, ligament) source of
  symptoms then NSAIDS, narcotics, antidepressant,
  cox-2 inhibitor, PT (exercise), /- muscle
  relaxants, /- chiropractor referral, /-
  acupuncture, /- behavioral therapy, ?corsets,
  ?massage, ?traction, ?TENS, ?epidural/facet
  injections, BUTcontinue ordinary activities in
  the acute period AND in the post-acute period
  begin conditioning activities to strengthen back,
  legs, abdomen to prevent recurrence
• /- some evidence ? unknown
• NEJM 332351-5, 1995
• JAMA 2721286-91, 1994

17
Evaluation of Lumbar Spine Disease

• Options when clinical suspicion low or diagnosis
  unclear
• 1. Observe (80-90 will resolve in lt6 weeks)
• most common diagnosis of acute (i.e. lt6 weeks)
  back pain lumbar strain
• pathobiology may be any pain sensitive structure
  muscle, tendon, ligaments, disc, facet joints,
  periosteum, meninges, blood vessels, or
  degenerative changes
• no controlled studies to correlate symptoms
  and imaging
• NSAIDS, narcotics, antidepressant, cox-2
  inhibitor, PT while you are observing
• 2. Imaging
• BUT ASK THE PATIENT are you willing to have
  surgery or other invasive procedure if we do this
  work up?
• For back pain pts 4 will have compression fx,
  1 will have a tumor, 3 will have a herniated
  disc

18
Imaging of Lumbar Spine Disease

• If clinical suspicion high for intraspinal source
  of symptoms i.e. radiculopathy, neurogenic
  claudication, lumbar instability, compression fx
  then
• 1) MRI, MRI, MRI unless there is a
  contraindication (see next slide)
• Add contrast only if patient has had prior
  surgery or a history of cancer perhaps with a
  demyelinating process like multiple sclerosis
• If not sure order without contrast and radiology
  will pick up the ones that do need it

19
Imaging of Lumbar Spine Disease

• 2) If there is a contraindication to MRI then CT
  myelogram (contraindications to MRI heart stent
  lt 2 weeks old, defibrillator, pacemaker, pain
  pump, spinal cord or deep brain stimulator, prior
  lumbar spine instrumentation, programmable shunt)
• Questions? call radiology or specialist involved
  in placing device or hardware
• If patient is too large for closed MRI then order
  open MRI
• CT is WAY OVERUTILIZED as a spine diagnostic test
  and delivers A LOT of radiation to the patient

20
Imaging of Lumbar Spine Disease

• 3) if signs of spondylolisthesis then
  flexion/extension x-rays (lateral)
• 4) pain medications (NSAIDS, narcotics, /- oral
  steroid taper, /- muscle relaxant)
• 5) Consultation after MRI or CT myelogram results
  show something other than degenerative changes

21
Consultation at the Spine Center

• Who should I send what to?
• General recommendations
• Acute pain problems surgeons pain management
• Surgeons usually after imaging
• Active smokers will be strongly encouraged to
  stop
• Poorly controlled diabetics (Hgb A1C gt 7) will
  result in re-evaluation request with primary care
  prior to surgery
• Pain management does not require imaging
• Chronic pain problems physiatry neurology
• Does not require imaging

22
SPORT Study

• Conservative therapy isnt the worst idea for
  patients with a herniated disc and mild to
  moderate symptoms
• 2-year prospective randomized trial of patients
  with radicular symptoms gt 6 weeks and imaging
  evidence of a herniated disc
• Randomized to surgery or PT, exercise, NSAIDS
• LOTS of patients cross-over to opposite group if
  symptoms are too mild or too severe
• BUT at 2-year follow-up, both surgery and
  conservative management was effective
• JAMA 20062962451-2459

23
Should I reimage?

• Have symptoms or signs changed significantly?
• Has there been a recent intervention (e.g.
  surgery) or trauma?
• Look at patients chart has it been gt1 year
  since last imaging?
• If the answer to these 3 questions is no then
  reimaging is not indicated

24
Summary

• Start with good history and physical
• Is this emergent, urgent or routine?
• Is the cause most likely disc, stenosis,
  instability, compression fracture or soft tissue?
• Typically start conservative and escalate as
  necessary