Common Pathologies of Spine

Swedish’s Orthopedics Symposium for Primary Care 11/12/2021

Common Pathologies of SpineSwedish Orthopedic Symposium for Primary Care

November 12, 2021

Wilson Chang MD MPHSwedish Health SystemSwedish Pain Services

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Overview• Basic Approach of Lumbar Spine • Common pathologies involving the Spine• Useful types of management• When to refer to specialist?

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American College of Physicians (ACP) Guidelines1

• Annals of Internal Medicine (Feb 2017)

• …treat acute and subacute back pain with non-drug therapies such as heat, manual therapy/massage, acupuncture.• If drug therapy, NSAIDs and muscle relaxants.• Acetaminophen is not effective at improving pain outcomes compared to placebo.• Low quality evidence that showed oral steroids is not effective for acute/subacute back pain.

• For chronic low back pain, need to stay conservative prior to being invasive.• Recommends multidisciplinary approach using exercise, mindfulness-based stress reduction (MBSR), acupuncture, CBT,

Biofeedback, etc.• If drug therapy, 1st line NSAIDs; 2nd line tramadol/duloxetine; opioids after having failed all the above and discussion of

risks/benefits.

• Jury is still out for radicular pain management.

1https://www.acponline.org/acp-newsroom/american-college-of-physicians-issues-guideline-for-treating-nonradicular-low-back-pain

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Common Pathologies of AXIAL pain

Acute/Subacute (<4 wks; 4-12 wks)• Discogenic

Incapacitating “bed ridden for a day”

Sudden onset w/ bending or twisting

Midline Focal w/ minimal radiation

Younger/healthier spine (<age 45)

Heat/Cold, PT NSAIDs, oral steroids*

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Nachemson 1966

Relative changes to Intradiscal Pressure/load of L3 intervertebral disc in various positions in living subjects.

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Common Pathologies of AXIAL painAcute/Subacute (<4 wks; 4-12 wks)

• Myofascial/trigger point Locking Tightness sensation Sudden onset Diffusely longitudinal along

thoracolumbar paraspinal muscles Younger patients Rare in elderly Heat/Cold, manual massage, deep

tissue mobilization, dry needling/IMS

NSAIDs, topical menthol-based patches (Biofreeze), muscle relaxants

• Compression Fx Incapacitating pleuritic pain Sudden onset Midline to paramidline focal but can also be

radiating pain Common in elderly Rule out pathologic fx in younger patients XR Heat/Cold, corsette/brace, PT but can make

pain worse NSAIDs, transdermal agents, short course of

low dose opioids Kyphoplasty

• Zebras Nephrolithiasis, pancreatitis Muscle/Ligament tears Osteomyelitis, discitis, epidural abscess

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Common Pathologies of AXIAL painChronic (>12 wks)

• Spinal stenosis Complex symptomatology (can

have radiating lower limb pain) Debilitating, not incapacitating Segmental pain (hand palms’

area) “Shopping cart sign” Common in elderly XR/MRI PT, epidural injection Surgical consultation for

weakness

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• Sacroiliac joint pain Debilitating w/ activity Buttock region “dimple”

near PSIS can radiate to hip/groin

Common in elderly Clinical diagnosis –

Fabers, thigh thrust, gaenslen’s

No need for XR* PT, SI joint belt, SI

injection

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• Hip arthropathy Frequently missed for SI joint pain Groin vs. buttock pain can radiate to thighs or

perineum FAIR/FADIR test osteoarthritis, labrum tear XR/MRI PT, hip injection

• Nociplastic pain Spectrum condition underlying central

sensitization of pain; altered pain perception; neuroplasticity

Multiple co-morbidities: fibromyalgia, IBS, EhlerDanlos, chronic fatigues syndrome

Important complete medical work up Multidisciplinary therapy program, CBT, behavioral

support NSAIDs, duloxetine, tramadol, neuropathic agents

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Common Pathologies of AXIAL painChronic (>12 wks)• Facet

arthropathy/Scoliosis Debilitating “annoying

always present” Paramidline radiating

in band-like fashion Can radiate to

glutes/thighs do not confuse with radicular “sciatic” pain

Common in elderly XR/MRI PT, radiofrequency

ablation

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Common Pathologies of RADICULAR painAcute/Subacute

• Radiculopathy Incapacitating “can’t move my legs” Sudden onset w/ bending or lifting Paramidline Focal w/ dermatomal

radiation Younger/healthier spine (active

patients) MRI/EMG PT, NSAIDs, oral steroids*,

neuropathic agents, epidural injection*

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Common Pathologies of RADICULAR painChronic

• Post laminectomy syndrome Relapse of radiating lower limb

pain can be axial back pain Neural irritation/compression

from bone, soft tissue, scar tissue post decompression surgery

Insidious onset History of spinal surgery Dynamic XR/MRI Neuropathic agents, epidural

injection/Spinal cord stim Surgical consultation

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Types of InterventionsPhysical Therapy

Flexion-biased program Facetogenic, spinal stenosis Rx “isometrics to progress to

flexion-biased program. Posterior kinetic chain. Hip/core strengthening. Nerve glides if radiating limb symptoms. 1-2 times per week for 4-6 weeks. Transition to HEP.”

Physical Therapy Extension-biased program Discogenic/mechanical/myofascial Rx “isometrics to progress to

extension-biased program. Hip/core strengthening. Deep tissue massage or mobilization. 1-2 times per week for 4-6 weeks. Transition to HEP.”

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Types of InterventionsEpidural Corticosteroid injection

Introduction of corticosteroids to a specific targeted area within the epidural space of spine.

Fluoroscopically guided injection. Radiculopathy, discogenic, spinal

stenosis

Peripheral joint Corticosteroid injection Introduction of corticosteroids to

a peripheral joint such as hips, SI joint.

Fluoroscopic or sonographic guidance.

SI joint pain, hip arthropathy

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Types of InterventionsRadiofrequency Ablation/neurotomy

Therapeutic thermal ablation of medial branch nerves which innervate the facet joints of the spine known to cause degenerative facetogenic pain.

Preserves the arthritic facet joint while ablating the nerve that detects facetogenic pain.

2 steps: Preceded by diagnostic nerve blocks to localize the spinal levels prior to ablation.

Facet arthropathy

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Types of InterventionsSpinal cord stimulator

Implantable spinal device designed to alter pain perception by creating a localized electrical field.

Electrodes are placed in epidural space connected to a generator/power source.

2 phases: trial and implantation. Refractory radiculopathy/stenosis,

post-laminectomy syndrome.

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Types of InterventionsKyphoplasty

Vertebral augmentation via injection of synthetic “cement” for pathologic and non-pathologic compression fractures.

60-90 min outpatient surgical procedure.

Immediate pain relief within 24-48hrs of procedure.

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When to Refer?

Monitor

Refer

Urgent

• Acute onset without neurological deficits.• Predominantly axial back pain.• Yet to try conservative treatment including, but not

limited to, PT, short-course of analgesics.• Basic radiographs or MRI.

• Refractory back pain or worsening symptoms having failed conservative treatment modalities like PT and first line analgesics.

• Acute on chronic symptomatology having tried various treatment options in the past.

• Radicular limb symptoms.• Optimization of pharmacotherapy.• Explore different interventions.

• Neurological deficits (weakness, gait abnormality, incontinence, saddle anesthesia, balance issues)

• Traumatic injury with significant decrement of functional ADL/IADL status.

• Severe structural deformity on advanced imaging.

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Common Pathologies of Spine

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