Differential Differential Diagnosis Diagnosis
of the of the SpineSpine
Paula Sammarone Turocy, EdD, ATCPaula Sammarone Turocy, EdD, ATCDuquesne UniversityDuquesne University
Etiology of Back PainEtiology of Back Pain
Reid DC. Sports Injury Assessment and Rehabilitation. New York, NY: Churchill Livingston. 1992.
““Red Flags” of Back PainRed Flags” of Back PainCancer Cancer (<1%)(<1%)
Patient Presentation: Unexplained weight Patient Presentation: Unexplained weight loss (>10%), past loss (>10%), past HxHx of cancer, night pain, of cancer, night pain, duration > 1 month, failure of conservative duration > 1 month, failure of conservative back treatmentback treatment
Spinal InfectionSpinal Infection (.01%)(.01%)Patient Presentation: Fever, chills, night pain Patient Presentation: Fever, chills, night pain that interrupts sleep, IV drug use, that interrupts sleep, IV drug use, HxHx of of infection elsewhereinfection elsewhere
““Red Flags” of Back PainRed Flags” of Back Pain
AnkylosingAnkylosing SpondylitisSpondylitis (.3%)(.3%)Inflammatory Inflammatory arthropathyarthropathy that first affects that first affects spine, then other joints and organsspine, then other joints and organsAs disease progresses, patient assumes As disease progresses, patient assumes fixed, stooped posture with flexion in lumbar fixed, stooped posture with flexion in lumbar spine, knees, and hips to decrease painspine, knees, and hips to decrease pain
““Red Flags” of Back PainRed Flags” of Back Pain--AnkylosingAnkylosing SpondylitisSpondylitis
Patient Presentation:Patient Presentation:Lumbar pain that resolves with activity Lumbar pain that resolves with activity occurs in men <40 occurs in men <40 yoyo, AM stiffness, night , AM stiffness, night pain, gradual onset, >3 months with pain, gradual onset, >3 months with symptomssymptoms
““Red Flags” of Back PainRed Flags” of Back PainCaudaCauda EquinaEquina SyndromeSyndrome
Compression on Compression on CaudaCauda EquinaEquina due to due to massive, central disc massive, central disc herniationsherniations (occurs in (occurs in only 1only 1--2% of all disc protrusions)2% of all disc protrusions)Requires surgical interventionRequires surgical interventionPatient Presentation:Patient Presentation: Bladder dysfunction Bladder dysfunction (urinary retention, increased frequency, (urinary retention, increased frequency, overflow, incontinence, saddle anesthesia, overflow, incontinence, saddle anesthesia, bilateral pain and/or weaknessbilateral pain and/or weakness
““Red Flags” of Back PainRed Flags” of Back PainCerebral Spinal Fluid LeakageCerebral Spinal Fluid Leakage
Usually occurs following back surgeryUsually occurs following back surgeryClear/slightly yellowClear/slightly yellow--tinged fluid slowly drips tinged fluid slowly drips from spinal incisionfrom spinal incisionAs amount of Cerebral Spinal Fluid loss As amount of Cerebral Spinal Fluid loss increases, patient develops followingincreases, patient develops following
Severe headacheSevere headacheNauseaNauseaSlight disorientation Slight disorientation
SciaticaSciaticaInjury, Problem, SymptomInjury, Problem, Symptom
Inflammation of the Sciatic Inflammation of the Sciatic Nerve (neuritis) usually Nerve (neuritis) usually associated with peripheral nerve associated with peripheral nerve root compressionroot compression
Sciatic Nerve is susceptible to Sciatic Nerve is susceptible to Torsion Torsion Direct blows Direct blows -- ischial tuberosity ischial tuberosity Compression Compression -- spasms/tightness in spasms/tightness in piriformis musclepiriformis muscle
SciaticaSciaticaMechanism of InjuryMechanism of Injury
Disc/nerve injuryDisc/nerve injuryHip Hip hyperflexionhyperflexionPiriformis pathologyPiriformis pathology
Patient Presentation:Patient Presentation:ParasthesiaParasthesia/anesthesia along /anesthesia along portion/length of nerve (portion/length of nerve (proximalproximal distaldistal))Muscle weaknessMuscle weaknessPossible decrease in Achilles/Hamstring Possible decrease in Achilles/Hamstring reflexesreflexes
Sciatica Presentation and TreatmentSciatica Presentation and Treatment
Treat according to magnitude of symptoms and findings of screening tests.
Plain films of lumbar spine. Consider complete blood screen. ESR. Acid and alkaline phosphatase. Bone scan. Where diagnosis not apparent, CT or MRI. Chest film.
Sciatica with atypical features such as fever, weight loss, chronic cough, abdominal pain, altered bowel habits or rectal bleeding, long tract signs or onset in very young or elderly.
Detailed active history. Modify activity appropriately. Therapy. NSAIDS. If improves progress PRN.
Plain films of lumbar spine. If no improvement at 6 weeks, consider further investigation.
Sciatica only. Sensory normal. Muscle normal.
Take careful history. Elicit aggravating factors. Two weeks rest from activity. Therapy. NSAIDS. If no improvement, further modify activity. If improves, progress PRN.
Plain lumbar spine films. If not improvement at 6 weeks, consider further investigation.
Sciatica, sensory changes, mild or no reflex changes. Normal muscle strength. Bladder normal.
Treat as above.Consider above investigations immediately.
Sciatica. Reflex changes. Muscle weakness. Normal bladder function. Repeat or chronic
Complete withdrawal from activity. Modified activity for few days according to pain. NSAIDS, analgesics. Therapy. If improves, progress treatment as per symptoms.
Plain films of lumbar spine. If improves in 10-14 days, follow patient. If not, consider CT, MRI, or myelogram.
Sciatica. Reflex changes. Muscle weakness. Normal bowel and bladder function. Acute onset.
Consider immediate surgical decompressions
CT Scan or MRISciatica. Reflex changes. Muscle weakness. Altered bladder function
TreatmentInvestigationCondition at Presentation
Common Pathologies of the SpineCommon Pathologies of the SpineFacet Joint InjuriesFacet Joint Injuries
Normally nonNormally non--weight weight bearing jointbearing joint
Becomes weight bearing Becomes weight bearing with increased trunk with increased trunk extensionextension
Trunk extension also Trunk extension also places stress on places stress on longitudinal ligamentslongitudinal ligaments
Injury may be to Injury may be to capsule or capsule or meniscalmeniscal--like like structure in jointstructure in joint
Facet Joint InjuryFacet Joint InjuryPatient Presentation:Patient Presentation:
Back Pain > Leg PainBack Pain > Leg PainPain increases with standing, sitting, walkingPain increases with standing, sitting, walkingPain with rolling over in bedPain with rolling over in bedPain with trunk extension and rotationPain with trunk extension and rotation+ SLR+ SLRPt tender over lateral to spinous process Pt tender over lateral to spinous process (over facet joint)(over facet joint)
Common Pathologies of the Common Pathologies of the SpineSpine
Disc InjuryDisc InjuryPain produced is as a result of Pain produced is as a result of
Associated nerve being stretched across and Associated nerve being stretched across and pressed upon the bulging disc into the pressed upon the bulging disc into the posterolateral space posterolateral space and/orand/orChange of spinal mechanics that result in Change of spinal mechanics that result in abnormal function at the vertebral jointabnormal function at the vertebral joint
90% of disc injuries occur at L490% of disc injuries occur at L4 S1S1
Only 1% of those diagnosed cases occur in Only 1% of those diagnosed cases occur in 1010--20 year olds20 year olds
Annular Fibrosus TearAnnular Fibrosus TearUsually a circular or “bucket Usually a circular or “bucket handle” tear that occurs in the handle” tear that occurs in the annular fibersannular fibers
Patient Presentation:Patient Presentation:Pain with twisting/bending Pain with twisting/bending (torsion) type motion(torsion) type motionPain mostly in center of spinePain mostly in center of spineNormal SLR test, because Normal SLR test, because usually no nuclear bulgeusually no nuclear bulge+ MRI+ MRI
Schmorl’sSchmorl’s NodesNodes
Pressure on the disc becomes great Pressure on the disc becomes great enough to cause defects in cartilaginous enough to cause defects in cartilaginous end plateend plate
Pressure causes Pressure causes herniationherniation of the nucleus of the nucleus pulposus into the vertebral bodypulposus into the vertebral body
Normal fluid mechanics of the disc Normal fluid mechanics of the disc become impaired/disruptedbecome impaired/disrupted
Normal and Impaired Disc FunctionNormal and Impaired Disc Function((Schmorl’sSchmorl’s Nodes/End Plate Fracture)Nodes/End Plate Fracture)
Nucleus Pulposus InjuriesNucleus Pulposus InjuriesProgression of Nucleus Pulposus Injury
1.1. Disc ProtrusionDisc Protrusion2.2. Disc ProlapseDisc Prolapse3.3. Disc ExtrusionDisc Extrusion4.4. Sequestrated DiscSequestrated Disc
Nucleus Pulposus InjuriesNucleus Pulposus InjuriesDisc ProtrusionDisc Protrusion
The nucleus pulposus of the disc The nucleus pulposus of the disc begins to bulge posteriorly without begins to bulge posteriorly without rupturing the annulus rupturing the annulus fibrosusfibrosus
Disc ProlapseDisc ProlapseOnly the outermost fibers of the Only the outermost fibers of the annulus fibrosus can contain the annulus fibrosus can contain the nucleusnucleus
Nucleus Pulposus InjuriesNucleus Pulposus InjuriesDisc ExtrusionDisc Extrusion
The nucleus pulposus moves into The nucleus pulposus moves into the epidural space, placing pressure the epidural space, placing pressure on nerve rooton nerve root
Sequestrated DiscSequestrated DiscFormation of Formation of discaldiscal fragments that fragments that may leave the disc area after the may leave the disc area after the nucleus and annulus fibrosus nucleus and annulus fibrosus rupturesruptures
Pain from Nerve Root PressurePain from Nerve Root Pressure
McKenzie DerangementsMcKenzie Derangements
SacroSacro--iliac Joint (SI Joint)iliac Joint (SI Joint)DiarthroidialDiarthroidial joint until early in adult lifejoint until early in adult life
ROM decreases and joint may become ROM decreases and joint may become ankylosedankylosed during aging process during aging process
arthrosisarthrosis
No muscles actually move the SI joint; No muscles actually move the SI joint; joint supported solely from capsules and joint supported solely from capsules and ligamentsligaments
SI Joint DysfunctionSI Joint DysfunctionMechanism Mechanism
Ilia(iliumIlia(ilium) wedging and ) wedging and locking with sacrumlocking with sacrumResult of abnormal pelvic Result of abnormal pelvic motion and/or rotation on motion and/or rotation on the sacrumthe sacrum
Common mechanismsCommon mechanismsHurdling/puntingHurdling/puntingChange of terrainChange of terrainChronic crownedChronic crowned--road runningroad runningStepping in hole or off curbStepping in hole or off curbAbnormal heel strike and/or Abnormal heel strike and/or running techniquerunning technique
SI DysfunctionSI DysfunctionPatient Presentation:Patient Presentation:
May occur secondarily to lower leg injury that results May occur secondarily to lower leg injury that results in irregular mechanicsin irregular mechanicsPain increases with sittingPain increases with sittingPain and limited ROM with same side sidePain and limited ROM with same side side--bendingbendingPain when going down stairsPain when going down stairsHeaviness or dullness in legHeaviness or dullness in legPossible impaired reflexesPossible impaired reflexesIlium position either anterior or posterior to neutralIlium position either anterior or posterior to neutral
SI Dysfunction Special TestsSI Dysfunction Special TestsSI CompressionSI CompressionSI Distraction (Spring) SI Distraction (Spring) SI Rock TestsSI Rock TestsFABERFABERProne Knee Flexion TestProne Knee Flexion TestLong Sitting TestLong Sitting TestSI Fixation TestSI Fixation TestStanding Flexion TestStanding Flexion TestSphinx TestSphinx Test
SpondylolysisSpondylolysisFracture of the Pars Fracture of the Pars InterarticularisInterarticularis
Etiology debateEtiology debate
Mechanism:Mechanism:GravitationallyGravitationally--related to related to hyperlordosishyperlordosisSevere impact to low back Severe impact to low back forcing forcing hyperlordosishyperlordosisChronic stress to low backChronic stress to low back
Occurs in 6Occurs in 6--10% of normal 10% of normal populationpopulation
SpondylolysisSpondylolysisUsually associated with segmental Usually associated with segmental lordosislordosisOften palpable bony prominence in Often palpable bony prominence in lumbosacrallumbosacral segmentsegmentDiagnosisDiagnosis
AP/Lateral/Oblique* radiographsAP/Lateral/Oblique* radiographsBone scan if stress fractureBone scan if stress fractureAppears as a “Scotty Dog” with a collarAppears as a “Scotty Dog” with a collar
SpondylolysisSpondylolysisPatient Presentation:Patient Presentation:
Point TendernessPoint TendernessPain increases with activityPain increases with activityConstant pain regardless of weightConstant pain regardless of weight--bearing bearing statusstatusSciaticaSciaticaMuscle weakness/atrophyMuscle weakness/atrophyPossible impaired reflexesPossible impaired reflexesPositive OnePositive One--Leg Standing TestLeg Standing Test
SpondylolisthesisSpondylolisthesisShift of the vertebral body Shift of the vertebral body anteriorlyanteriorly away away from the from the spinousspinous process following a process following a spondylolysisspondylolysisMay occur gradually May occur gradually Greater slippageGreater slippage more unstable more unstable Diagnosis by xDiagnosis by x--ray onlyray only>1 cm slippage >1 cm slippage neurological pathologyneurological pathologyMechanism Mechanism
Same as Same as spondylolysisspondylolysis
Types of Types of SpondylolisthesisSpondylolisthesisDysplasticDysplastic
Congenital anomalies in upper sacrum or posterior Congenital anomalies in upper sacrum or posterior arch of L5arch of L5
IsthmicIsthmicDefect in Pars Defect in Pars InterarticularisInterarticularis, or fatigue fracture in , or fatigue fracture in bone, or elongated area with pars in tactbone, or elongated area with pars in tact
DegenerativeDegenerative
TraumaticTraumatic
PathologicPathologic
SpondylolisthesisSpondylolisthesisPatient Presentation (General):Patient Presentation (General):
Point tendernessPoint tendernessActivity and weight bearing increases painActivity and weight bearing increases painSciaticaSciaticaMuscle weakness and/or atrophyMuscle weakness and/or atrophyPossible impaired reflexesPossible impaired reflexes
Grade 1 Grade 1 SpondylolisthesisSpondylolisthesisArch defect in L5Arch defect in L5Mild forward slippage Mild forward slippage of L5 on S1of L5 on S1BackacheBackacheNo gross instabilityNo gross instability
Grade 2 Grade 2 SpondylolisthesisSpondylolisthesisMore slippage More slippage between L4between L4--L5 with L5 with collapse of disccollapse of discDefinite symptomatic Definite symptomatic backbackRestricted ROMRestricted ROMMuscle spasmsMuscle spasmsRestricted activitiesRestricted activities
Grade 3 Grade 3 SpondylolisthesisSpondylolisthesisMore extensive More extensive slippage with wide slippage with wide separation of arch separation of arch defectdefectDegenerative Degenerative changes in discchanges in discGrossly symptomaticGrossly symptomaticGreat instabilityGreat instability
Grade 4 Grade 4 SpondylolisthesisSpondylolisthesis
Vertebrae slipped Vertebrae slipped forward more than forward more than 50%50%Severe disabilitySevere disabilitySevere instabilitySevere instability
SpinaSpina BifidaBifidaDysplasticDysplastic congenital defects congenital defects
Malformation of the posterior aspect of the Malformation of the posterior aspect of the spinal column in which some portion of the spinal column in which some portion of the vertebral arch fails to form over the spinal vertebral arch fails to form over the spinal cordcord
1/1000 infants born with this defect1/1000 infants born with this defectAthletes may develop neurological Athletes may develop neurological impairmentsimpairmentsMeningesMeninges may/may not be distendedmay/may not be distended
SpinaSpina BifidaBifidaMechanismMechanism
NoneNone
Patient Presentation:Patient Presentation:Pain in localized or general area of spinePain in localized or general area of spinePossible instabilityPossible instabilityChronic neurological symptoms that are more Chronic neurological symptoms that are more difficult to resolve than normaldifficult to resolve than normalPalpable defect in spinePalpable defect in spine
Piriformis SyndromePiriformis SyndromeLow back pain in back, buttocks, posterior Low back pain in back, buttocks, posterior thigh caused by hyperirritability of the thigh caused by hyperirritability of the piriformis muscle piriformis muscle
Mechanisms:Mechanisms:(Trauma) Lifting heavy objects(Trauma) Lifting heavy objects(Indirect) Tight hip external rotators apply (Indirect) Tight hip external rotators apply pressure to sciatic nervepressure to sciatic nerve
Piriformis SyndromePiriformis SyndromePatient Presentation:Patient Presentation:
NonNon--specific sciatic painspecific sciatic painPain increases with prolonged sitting, getting Pain increases with prolonged sitting, getting up from sitting or at nightup from sitting or at nightTight and/or painful hip internal rotationTight and/or painful hip internal rotation
Special Tests:Special Tests:FABER testFABER testLasegueLasegue (SLR) test(SLR) testPain with resistive hip abductionPain with resistive hip abduction
Spinal Spinal StenosisStenosis ((SpondylosisSpondylosis))
Narrowing of spinal canal that places Narrowing of spinal canal that places pressure on nerve roots and/or spinal cordpressure on nerve roots and/or spinal cord
Mechanism:Mechanism:Arthritic changes and spurring vertebral Arthritic changes and spurring vertebral bodies (permanent condition)bodies (permanent condition)PseudoclaudicationPseudoclaudication (temporary (temporary condition)condition)
Spinal Spinal StenosisStenosisPatient Presentation:Patient Presentation:
Pain after long periods of walking or Pain after long periods of walking or prolonged standingprolonged standingIn true In true stenosisstenosis, when activity stops, pain , when activity stops, pain stopsstopsPain is alleviated with sitting or flexed posture Pain is alleviated with sitting or flexed posture to decrease to decrease lordosislordosisPositive Positive Milgrim’sMilgrim’s Test, SLR >70Test, SLR >7000
Erector Erector SpinaeSpinae StrainStrainMechanism:Mechanism:
Forced FlexionForced FlexionOveruse/abuse in hyperextensionOveruse/abuse in hyperextensionEccentric Loads to spine (lifting, gardening)Eccentric Loads to spine (lifting, gardening)
Patient Presentation:Patient Presentation:Acute onsetAcute onsetPain mostly in backPain mostly in backPain increases with passive flexionPain increases with passive flexionWeakness with trunk extensionWeakness with trunk extension
Erector Erector SpinaeSpinae StrainStrain
Special Tests:Special Tests:MMT for Erector MMT for Erector SpinaeSpinae (trunk extensors)(trunk extensors)Pain alleviated when muscles shortenedPain alleviated when muscles shortened
Thank YouThank YouPaula Sammarone Turocy, EdD, ATCPaula Sammarone Turocy, EdD, ATC
Department Chair & Associate ProfessorDepartment Chair & Associate ProfessorDuquesne UniversityDuquesne University
Pittsburgh, PAPittsburgh, PA