An Approach to the Lumbar Spine

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An Approach to the Lumbar Spine

• And a few comments on the sporting back
• David Humphries
• Sports Physician

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What will we cover

• Surface anatomy
• General anatomy and biomechanics of the L/S spine
• The ages of back pain
• Where does the pain come from
• Examination and investigation
• What can I do for the patients pain/dysfunction

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Quotable Quotes from Athens

• Paul Hamm, gymnast
• I owe a lot to my parents, especially my mother
  and father

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Surface anatomy
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Surface anatomy

• Need to identify the following
• Iliac crest
• Spinous processes
• Sacroiliac joints
• Lateral bony structures (TP and facet regions)
• PSIS
• Quadratus lumborum
• Iliopsoas

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General anatomy
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Biomechanics of stability(structuralists versus
functionalists)

• Static (bone/ligament/disc) and dynamic (muscle
  and IAP)
• Intra-abdominal pressure (IAP) assists in
  stabilising the disc
• Smaller deeper muscles stabilise segments prior
  to movement
• Larger superficial muscles move spine

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Biomechanics
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Video-analysis of Biomechanics
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The Ages of Back Pain

• Pre-teens back pain is rare, look for sinister
  causes and kyphoscoliosis
• Teenagers incidence 15 (often in thoracic spine)
  and 80 become chronic, think endplates,
  discitis, spondyolithesis, inflammatory
• 20s and 30s, disc injury and protrusion is
  common /- sciatica

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The Ages of Back Pain

• 40s/50s discal pain and protrusion but also
  increasingly facet arthropathy, foraminal
  stenosis

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The Ages of Back Pain

• 60 generalised degenerative disease, increasing
  rate of stenotic lesions both laterally and
  centrally, CPPD, DISH

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Quotable Quotes from Athens

• Boxing Analyst
• Sure there have been injuries, and even some
  deaths, but none of them really serious

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Where does lumbar pain come from?

• According to Bogduk and Schwartz
• using serial anaesthetic techniques
• the disc is responsible for 50
• the facet (ZA) joints 45
• everything else 5
• This may only be true in the lab

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Proving where it comes from.

• Ask the patient
• Examination observation, range, tenderness,
  neurological
• Many fancy examination systems exist but have
  poor inter-examiner reliability and variable
  diagnostic significance

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Proving where it comes from 2.

• In back pain no radiological investigation can be
  regarded as highly sensitive and highly specific
• With true referred pain CT and MR both have a
  place
• Gold standard? Probably highly selective medial
  branch blocks and provocation discography

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An obvious cause of back pain
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How do I treat it?

• Make a structural or functional diagnosis,
• then reconsider it
• Control the pain
• Stabilise the spine
• Rehabilitate function

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Quotable Quotes from Athens

• Basketball analyst
• He dribbles a lot and the opposition doesnt
  like it. In fact, you can see it all over their
  faces

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Hints

• Pain with flexion (including sitting) is more
  commonly discal in origin
• Pain with extension (including standing and slow
  walking) is more likely to be facetal in origin
• Night pain, morning stiffness, fevers should
  alert you

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Hints 2

• Dont forget back pain can be a sign of a disease

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Hints 3

• Dont forget back pain can be a sign of a syndrome

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Truths ?

• Most back pain does not resolve completely in 6
  weeks
• Most adults will experience back pain and in 80
  of them it will be recurrent
• If you have back pain that prevents you doing
  your normal job for gt12 months your chances of
  returning to that job are lt2

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Truths ?

• Manipulation has only been proven to be effective
  in acute back pain
• Surgery works best for sciatic pain and is much
  less successful in back pain
• No exercise program has been shown to reduce the
  long term recurrence of back pain

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Quotable Quotes from Athens

• Softball announcer
• If history repeats itself, I should think we can
  expect the same thing again

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The Sporting Back

• In teenagers sports that involve recurrent
  extension are more likely to lead to pars stress
  fractures
• Lifting and power sports are more likely to lead
  to discal injury
• Some activities lead to both (cricket fast
  bowlers)

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Some sports prone to back injury such as
gymnastics
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Time for a break

• And some examination practice