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Белорусский государственный медицинский университет

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Травматология и ортопедия

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Essentials of Orthopedic Surgery, third edition / 07-The Spine

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LBP (SCIATICA)

SYMPTOM

CT/MRI

LOW BACK PAIN ALGORITHM

YES

SIGN

SURGERY

CEC

MYELOGRAM

DIAGNOSTIC

(PROGRESSIVE WEAKNESS)

TEST

ACUTE

THERAPEUTIC

CONSTITUTIONAL SYMPTOMS

INTERVENTION

FULL

CONTROLLED PHYSICAL ACTIVITY

SUPPORT

EXERCISE

(UP TO 6 WKS) MEDICATIONS

YES

ACTIVITY

LBP

POSTERIOR

LEG PAIN

PREDOMINANT

THIGH PAIN

BELOW KNEE

PREDOMINANT

PLAIN

FULL

YES

LOCAL

HIP AND

YES

ARTHRITIS

EPIDURAL

YES

EXERCISE

FULL

EXERCISE

INJECTION

HERNIA

STEROIDS

ACTIVITY

X-RAYS (MOTION

EVALUATION

HERNIA

STUDIES)

BACK STRAIN

YES

NEURO/

LOCAL

TENSION

YES

SIGNS+

SIGNS-

INJECTION

IVP

KIDNEY

BACK STRAIN

AND/OR SUPPORT

DISC

INSTABILITY

DISORDER

PROTOCOL

YES

TREATMENT

YES

AS INDICATED

SPONDYLOLISTHESIS

CATMRI

SCAN

STRESS TEST

SCAN

CALCIFICATION

CAT/MRI

BONE

EXERCISE

DEGENERATION

SEGMENTAL

INSTABILITY

SCAN

GT-EMG

YES

DIABETES

YES

(FEMORAL

MEDICAL

FULL

OSTEOARTHRITIS

CPPD

YES

FULL

NEUROPATHY)

EVALUATION

TUMOR

ACTIVITY

ACROMEGALY

OCHRONOSIS

SUPPORT

PLAIN-RAYS

INFECTION

ACTIVITV

ISOLATED STENOSIS

L3-4 OR L4-5

CAT SCAN

YES

SURGERY

ABDOMINAL

MUSCLE PAIN

ESR

(SONOGRAM)

ANEURYSM

MYELOGRAM

CAT SCAN

STIFFNESS

YES

EPIDURAL

EXERCISE

YES

STEROIDS

FULL

YES

ACTIVITY

LOW BACK SCHOOL

MEDICAL

HNP

POLYMYALGIA FIBROSITIS

BACK STRAIN

EVALUATION

RHEUMATICA

FULL

PROTOCOL

MYELOGRAM

PSYCHO-

ACTIVITY

INVASIVE

MYELOGRAM

PROCEDURE

SOCIAL

SURGERY/

EVALUATION

CHEMONUCLEOLYSIS

YES

SPINAL STENOSIS

TREATMENT

PERIODIC

RE·EVALUATION

SURGERY

INDICATED

FIGURE 7-12. Algorithm for the differential diagnosis of low back pain. (From Boden S, Wiesel SW, Laws E, et al. The Aging Spine. Philadelphia: Saunders, 1991. Reprinted by permission.)

.al et Wiesel .W.S 316

7. The Spine

317

the aim of which is to select the correct diagnostic category and proper treatment avenues for each patient with low back pain. A speciﬁc patient may fall outside the limits of the algorithm and require a different approach, and the physician must constantly be on the alert for exceptions. The algorithm can be followed in sequence and is also presented in table form (Table 7-4).

The information necessary to use the algorithm is initially obtained through the history and physical examination. The key points in the history are differentiation of back pain that is mechanical in nature from nonmechanical pain which is present at rest, detecting changes in bowel or bladder function, and deﬁning the precise location and quality of the pain. The physical examination must be oriented toward ruling out other medical causes of low back pain, assessing neurologic function, and evaluating for the presence of tension signs.

Following the low back pain algorithm, the ﬁrst major decision is to make a ruling on the presence or absence of CEC syndrome. Mechanical compression of the cauda equina, with truly progressive motor weakness, is the only surgical emergency in lumbar spine disease. This compression from a massive rupture of the L4–L5 disk in the midline is usually caused by pressure on the caudal sac, through which pass the nerves to the lower extremities, bowel, and bladder.

The signs and symptoms of CEC are a complex mixture of low back pain, bilateral motor weakness of the lower extremities, bilateral sciatica, saddle anesthesia, and even frank paraplegia with bowel and bladder incontinence or urinary retention. CEC can be caused by either bone or soft tissue damage, the latter generally a ruptured or herniated disk in the midline. These patients should undergo an immediate deﬁnitive diagnostic test and, if it is positive, emergency surgical decompression. Historically, the myelogram was the study used in this setting; however, the development of the MRI has facilitated the noninvasive diagnosis of CEC. The principal reason for prompt surgical intervention is to arrest the progression of neurologic loss; the chance of actual return of lost neurologic function following surgery is small. Although the incidence of CEC syndrome in the entire back pain population is very low, it is the only event that requires immediate operative intervention; if its diagnosis is missed, the consequences can be devastating.

The remaining patients make up the overwhelming majority. They should be started on a course of conservative (nonoperative) therapy regardless of the diagnosis. At this stage the speciﬁc diagnosis, whether a herniated disk or simple back strain, is not important to the therapy because the entire population is treated the same way. A few of these patients will eventually need an invasive procedure (surgery), but at this point there is no way to predict which individuals will respond to conservative therapy and which will not.

TABLE 7-4. Differential diagnosis of low back pain.

		Herniated
	Back	nucleus	Spinal	Spondylolisthesis/
Evaluation	strain	pulposus	stenosis	instability	Spondyloarthropathy	Infection	Tumor	Metabolic	Hematologic	Visceral
Predominant	Back	Leg	Back/leg	Back	Back	Back	Back	Back	Back	Back
pain (arm vs.		(below								(buttock,
neck)		knee)			+	+	+	+	+	thigh)
Constitutional					+	+	+	+	+
symptoms		+		−
Tension sign		+		−
Neurologic exam		−	− After
			stress
Plain X-rays			+	+	+	−	−	+	+
Lateral motion				+
X-rays		+	+			+	+			+
CT/MRI		+	+			+	+			+
Myelogram		+	+		+	+	+	+	+
Bone scan					+	+	+	+	+
ESR					+	+	+		+	+
Serum							+	+	+	+
chemistries

Ca/P/alk phos, calcium, phosphate, and alkaline phosphatase; CT, computerized tomography; MRI, magnetic resonance imaging; ESR, erythrocyte sedimentation rate.

7. The Spine

319

Conservative Treatment

Most of this initial group have nonradiating low back pain, termed lumbago or back strain. The etiology of lumbago is not clear. There are several possibilities, including ligamentous or muscular strain, continuous mechanical stress from poor posture, facet joint irritation, or a small tear in the annulus ﬁbrosis. Patients usually complain of pain in the low back, often localized to a single area. On physical examination they demonstrate a decreased range of lumbar spine motion, tenderness to palpation over the involved area, and paraspinal muscle spasm. Their roentgenographic examinations are usually normal, but if therapy is not successful, ﬁlms should be obtained to rule out other possible etiologic factors. Two exceptions to this rule are patients younger than 15 years of age and patients over age 60; X-rays are important early in the diagnostic process because these patients are more likely to have a diagnosis other than back strain (tumor or infection). Other situations warranting X-rays sooner rather than later include a history of serious trauma, known cancer, unexplained weight loss, and fever.

The early stage of the treatment of low back pain (with and without leg pain) is a waiting game The passage of time, the use of antiinﬂammatory medication, and controlled physical activity are the modalities proven safest and most effective. Most of these patients respond to this approach within the ﬁrst 10 days, although a small percentage does not. In today’s society with its emphasis on quick solutions and high technology, many patients are pushed too rapidly toward more complex (i.e., invasive) management. This quick-ﬁx approach has no place in the treatment of low back pain. The physician should treat the patient conservatively and wait as long as 6 weeks for a response. As already stated, most of these patients will improve within 10 days; some need a longer time.

Once the patients have achieved approximately 80% relief, they should be mobilized with the help of a lightweight, ﬂexible corset. After they are more comfortable and have increased their activity level, they should begin a program of lumbar exercises and return to their normal lifestyle. The pathway along this section of the algorithm is a two-way street: should regression occur with exacerbation of symptoms, the physician can resort to more stringent conservative measures. The patient may require further bed rest. Most acute low back pain patients will proceed along this pathway, returning to their normal life patterns within 2 months of onset of symptoms.

If the initial conservative treatment regimen fails and 6 weeks have passed, symptomatic patients are sorted into four groups. The ﬁrst group is composed of people with low back pain predominating. The second group complains mainly of leg pain, deﬁned as pain radiating below the knee and commonly referred to as sciatica. The third group has posterior thigh pain, and the fourth group has anterior thigh pain. Each group follows a separate diagnostic pathway.

320 S.W. Wiesel et al.

Refractory Patients with Low Back Pain

Those patients who continue to complain predominantly of low back pain for 6 weeks should have plain X-rays carefully examined for abnormalities. Spondylolysis with and without spondylolisthesis is the most common structural abnormality to cause signiﬁcant low back pain. Approximately 5% of the population has this defect, thought to be caused by a combination of genetics and environmental stress. In spite of this defect, most people are able to perform their activities of daily living with little or no discomfort. When symptoms are present, these patients usually respond to nonoperative measures, including a thorough explanation of the problem, a back support, and exercises. In a small percentage of such cases, conservative treatment fails and a fusion of the involved spinal segments becomes necessary. This is one of the few times primary fusion of the lumbar spine is indicated, and it must be stressed that it is a relatively infrequent occurrence.

Most patients with pain predominantly in the low back have normal plain X-rays. Before there is any additional workup, a local injection of steroids and Xylocaine may be tried at the point of maximum tenderness. This intervention can be quite successful, and if there is a good response, the patient is begun on exercises with gradual resumption of normal activity. In some instances, if there are no objective ﬁndings, such a trigger-point injection can be considered as early as the third week after onset of symptoms.

Should the patient not respond to local injection, other pathology must be seriously considered. A bone scan, along with a general medical evaluation, should be obtained. The bone scan is an excellent tool, often identifying early bone tumors or infections not visible on routine radiographic examinations. It is particularly important to obtain this study in the patient with nonmechanical back pain. If the pain is constant, unremitting, and unrelieved by postural adjustments, more often than not the correct diagnosis is an occult neoplasm or metabolic disorder not readily apparent from other testing.

Approximately 3% of cases of apparent low back pain that present at orthopedic clinics are attributable to extraspinal causes. A thorough medical search also frequently reveals problems missed earlier such as a posterior penetrating ulcer, pancreatitis, renal disease, or an abdominal aneurysm. If these diagnostic studies are positive, the patient should be transferred into a nonorthopedic treatment mode and would no longer be in the therapeutic algorithm.

Those patients who have no abnormality on their bone scans and do not show other medical disease as a cause for their back pain are then referred for another type of therapy: low back education. It is believed that many of these patients are suffering from discogenic pain or facet joint pain syndrome. The low back education concept has as its basis the belief that

7. The Spine

321

patients with low back pain, given proper education and understanding of their disease, can often return to a productive and functional life. Ergonomics, the proper and efﬁcient use of the spine in work and recreation, is stressed. Back education need not be an expensive proposition. It can be a one-time classroom session with a review of back problems and a demonstration of exercises with patient participation. This type of educational process has proved to be very effective. It is most important, however, that patients be thoroughly screened before they are referred to this type of program. One does not want to be in the position of treating a metastatic tumor in a classroom.

If low back education is not successful, the patient should undergo a thorough psychosocial evaluation in an attempt to explain the failure of the previous treatments. This step is predicated on the knowledge that a patient’s ability is related not only to his or her pathologic anatomy but also to the patient’s perception of pain and stability in relation to the social environment. It is quite common to see a stable patient with a frank herniated disk continue working, regarding the disability as only a minor problem, while a hysterical patient takes to bed at the slightest twinge of low back discomfort.

Drug habituation, depression, alcoholism, and other psychiatric problems are seen frequently in association with back pain. If the evaluation suggests any of these problems, proper measures should be instituted to overcome the disability. There are a surprising number of ambulatory patients addicted to commonly prescribed medications using complaints of back pain as an excuse to obtain these drugs. Oxycodone (Percodan) and diazepam, alone or in combination, are the two most popular offenders. Oxycodone is truly addictive; diazepam is both habituating and depressing. Because the complaint of low back pain may be a common manifestation of depression, it is counterproductive to treat such patients with diazepam.

Approximately 2% of patients who initially present with low back pain will fail treatment and elude any diagnosis. As there is no evidence of any structural problem in the back or criteria for any underlying medical disease or psychiatric disorder, this is a very difﬁcult group to manage. The authors’ strategy has been to discontinue narcotics, reassure patients, and periodically reevaluate them. Over time, one-third of these patients will be found to have an underlying medical disease; thus, one cannot abandon this group and discontinue treatment. For the remainder, as much physical activity as possible should be encouraged.

Refractory Patients with Sciatica

The next group of patients consists of those with sciatica, which is pain radiating below the knee. These patients usually experience their symptoms secondary to mechanical pressure and inﬂammation of the nerve

322 S.W. Wiesel et al.

roots that originate in the back and extend down the leg. The etiology of the mechanical pressure can be soft tissue, that is, a herniated disk, or bone, or a combination of the two.

At this point in the algorithm, the patient has had up to 6 weeks of controlled physical activity and medication but still has persistent leg pain. The next therapeutic step is an epidural steroid injection, which is performed on an outpatient basis. An epidural injection is worth trying; the chance of success is 40% and morbidity is low, particularly compared with the next treatment step—surgery. The maximum beneﬁt from a single injection is achieved at 2 weeks. The injection may have to be repeated once or twice, and 4 to 6 weeks should pass before its success or failure is judged.

If epidural steroids are effective in alleviating patients’ leg pain or sciatica, they are begun on a program of back exercises and encouraged to return promptly to as normal a lifestyle as possible. Should the epidural steroids prove ineffective, and 3 months have passed since the initial injury without relief of pain, some type of invasive treatment should be considered. The patient group is then divided into those with probable herniated disks and those with symptoms secondary to spinal stenosis.

The physician must now carefully reevaluate the patient for a neurologic deﬁcit and for a positive tension sign or SLRT. For those who have either a neurologic deﬁcit or positive tension signs along with continued leg pain, an MRI scan should be obtained. If the MRI scan is clearly positive and correlates with the clinical ﬁndings, there is no need for myelography because it is invasive.

As in the cervical spine, there is repeated documentation that for surgery to be effective in treatment of a herniated disk, the surgeon must ﬁnd unequivocal operative evidence of a nerve root compression. Accordingly, nerve root compression must be ﬁrmly substantiated preoperatively, not only by neurologic examination but also by radiographic data. There is no place for “exploratory” back surgery. Many asymptomatic patients have been found to have abnormal myelograms, EMGs, CT scans, and MRI scans. If the patient has neither a neurologic deﬁcit nor a positive SLRT, then regardless of radiographic ﬁndings there is not enough evidence of root compression to proceed with successful surgery. These patients without objective ﬁndings are the ones who have poor results and who have given back surgery a bad name.

If there are no objective ﬁndings, the physician should avoid surgery and proceed to the psychosocial evaluation. Exceptions should be few and far between. When sympathy for the patient’s complaints outweighs the objective evaluation, surgery is fraught with difﬁculties. For those who meet these speciﬁc criteria for lumbar laminectomy, results are satisfactory: 95% of them can expect a good-to-excellent result.

The second group of patients whose symptoms are based on mechanical pressure on the neural elements are those with spinal stenosis. The diagnosis of spinal stenosis usually can be inferred from the plain X-rays, which

7. The Spine

323

FIGURE 7-13. Computerized tomography scan of a 68-year-old man with back pain that is exacerbated with standing. Cross-sectional views demonstrate vacuum phenomenon in intervertebral disk (white arrow) and facet hypertrophy (most prominent on the right), resulting in canal stenosis at multiple levels (black arrows). The patient’s symptoms responded to epidural steroid injections. (From Borenstein DG, Boden S, Wiesel SW. Low Back Pain: Medical Diagnosis and Comprehensive Management, 2nd ed. Philadelphia: Saunders, 1995. Reprinted by permission.)

will demonstrate facet degeneration, disk degeneration, and decreased interpedicular and sagittal canal diameters. A CT scan and/or MRI can conﬁrm the diagnosis (Figs. 7-13, 7-14). If symptoms are severe, and there is radiographic evidence of spinal stenosis, surgery is appropriate. Age alone is not a deterrent to surgery; many elderly people who are in good health except for a narrow spinal canal will beneﬁt greatly from adequate decompression of the lumbar spine.

Refractory Patients with Anterior Thigh Pain

A small percentage of patients have pain that radiates from the back into the anterior thigh, which usually is relieved with rest and antiinﬂammatory medication. If the discomfort persists after 6 weeks of treatment, a workup should be initiated to search for underlying pathology. Although an upper lumbar radiculopathy can cause anterior thigh pain, several other entities must be considered.

A hip problem or hernia can be ruled out with a thorough physical examination. If the hip examination is positive, radiographs should be obtained. An IV pyelogram is useful to evaluate the urinary tract, because kidney stones often may present as anterior thigh pain. Peripheral neuropathy, most commonly secondary to diabetes, also can present initially with anterior thigh pain; a glucose tolerance test as well as an EMG will reveal the underlying problem. Finally, a retroperitoneal tumor can cause symptoms by mechanically pressing on the nerves that innervate the anterior thighs. A CT or MRI scan of the retroperitoneal area will eliminate or conﬁrm this possibility.

324 S.W. Wiesel et al.

FIGURE 7-14. Magnetic resonance imaging of the lumbar spine. Sagittal view of a T2-weighted image demonstrates foraminal narrowing at the L5–S1 interspace (black arrow) with associated intervertebral disk degeneration. (From Borenstein DG, Boden S, Wiesel SW. Low Back Pain: Medical Diagnosis and Comprehensive Management, 2nd ed. Philadelphia: Saunders, 1995. Reprinted by permission.)

If any of the entities just reviewed is diagnosed, the patient is treated accordingly. If no physical cause can be found for the anterior thigh pain, the patient is treated for recalcitrant back strain by the method already outlined.

Refractory Patients with Posterior Thigh Pain

This ﬁnal group of patients complains of back pain with radiation into the buttocks and posterior thighs. Most of them will be relieved of their symptoms with 6 weeks of conservative therapy. However, if their pain persists after the initial treatment period, they can be considered to have back strain and given a trigger-point injection of steroids and Xylocaine in the area of maximum tenderness. If the injection is unsuccessful, it is necessary to distinguish between referred and radicular pain.

As noted earlier, referred pain is pain in the mesodermal tissues of the same embryologic origin. The muscles, tendons, and ligaments of the buttocks and posterior thigh have the same embryologic origin as those of the low back. When the low back is injured, the pain may be referred to the posterior thigh, where it is perceived by the patient. Referred pain from irritated soft tissues cannot be cured with a surgical procedure.

7. The Spine

325

Radicular pain is caused by compression of an inﬂamed nerve root along the anatomic course of the nerve. A herniated disk or spinal stenosis in the high lumbar area can cause radiation or pain into the posterior thigh. An MRI or CT scan and an EMG may be used in this situation to differentiate radicular etiology from referred pain or a peripheral nerve lesion. If the studies are within normal limits, the patient is considered to have back strain and treated accordingly to the algorithm. If a radicular abnormality is found, the patient is diagnosed as having mechanical compression on the neural elements either from a herniated disk or spinal stenosis. Epidural steroids should be tried ﬁrst; if these do not provide adequate relief, surgery should be contemplated.

This group of patients with unexplained posterior thigh pain is very difﬁcult to treat. The biggest mistake made is the performance of surgery on people thought to have radicular pain who actually have referred pain. Again, referred pain in this setting is not responsive to surgery.

In most instances, the treatment of low back pain is no longer a mystery. The algorithm described here presents a series of easy-to-follow and clearly deﬁned decision-making processes. Use of this algorithm provides patients with the most helpful diagnostic and therapeutic measures at the optimal time. It neither denies them helpful surgery nor subjects them to procedures that are useless technical exercises.

Conservative Treatment Modalities

As the algorithm indicates, all low back pain patients, regardless of diagnosis (except those with CEC syndrome), require an initial period of conservative therapy. At present, there are many modalities available, but few have been scientiﬁcally validated because of the difﬁculty in performing a prospective double-blind study in this ﬁeld. Each treatment plan in popular use today is surrounded by conﬂicting claims for its indications and efﬁcacy. The purpose of this section is to discuss the rationale behind the use of some of the more common therapeutic measures.

Bed Rest (Controlled Physical Activity)

Decreased activity has evolved over the years as one of the most important elements in the treatment of low back pain. The degree of rest depends on the severity of the symptoms and can vary from complete bed rest to just a decrease in active exercise.

The amount of rest prescribed varies for each patient; these people should not be mobilized until reasonably comfortable. The type of pathology will determine the duration of rest required. Most patients with acute back strain will need only 2 to 7 days of bed rest before they can ambulate.

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