| Treatment of lumbar problems is very straightforward and follows a few anatomic principles. The information in this presentation will allow you to treat over 90% of office complaints in a very competent and thorough fashion.
About 90% of lumbar complaints resolve with in six weeks regardless of
therapeutic intervention. A few patients will require some formidable intervention to improve. Recurrent bouts of symptoms are heralding the deterioration of one or more spinal segments; therefore intervention should be introduced when feasible to diminish stressors on the spinal segment to prevent future deterioration. Stressors are inappropriate body mechanics, work ergonomics, postural dysfunction and lack of understanding by the patient of his role in creation of the problem.
Though 90% of people have some back problem in their life 10% who do
not have self limiting problems account for 90% of the expense.
Anatomic Principles
Three joint complex (motion segment): Disc and right and left facet joints allow for motion and stability between vertebra. These are interrelated in terms of function. When disc deteriorates facets will follow. Disc deterioration is a normal process related to cross linking of the mucopolysaccharide in the nucleus of the disc and the fibrocartilage of the annulus fibrosis. There are pain receptors in the outer wall of the annulus fibrosis. The rate of deterioration is the result of both congenital and environmental factors.
Over time loss of disc height results in a degenerative cascade with
deterioration of all components of the motion segment eventuating in segment
instability and ultimately in spinal stenosis. During this process discs
may herniate, and/or become internally torn and chronically painful on the
inside (internal disc disruption), facet joints may become overloaded, osteophytes may entrap neural elements or any combination of these. Any amount of abnormal motion will tend to make the problem more symptomatic. Voluntary skeletal musculature has some ability to cope with these problems.
Spondylolysis is a defect in the lamina which connects the superior and
inferior facet articular processes of a vertebra. This may result in slippage
of one vertebra upon another which often results in destabilization and
stenosis of that level and disc degeneration often of the disc above the
defective vertebra. It is common; about 3% incidence and often asymptomatic.
Treatment
Conservative Principles
-reverse the mechanism of injury if identifiable
-follow the patients pain pattern
The most common lesion is the annulus tear. It is recognized by a flexion
mechanism of injury, no neurologic deficit, worsening by positions of increased
disc loading (flexion) and relief in positions of lumbar extension. Initial
treatment is stabilization in extension. Severe pain can be eliminated in
minutes in your office and the problem often largely resolved in 72 hours
if the patient sticks to an appropriate regimen. If the tear becomes a chronic
resistant problem we call it a bulging disc syndrome (a annulus tear that
won't heal). This characterized by chronic flexion intolerance due to back
pain. Treatment is the same.
Facet joint strain, sprain, or arthropathy is typified by increased symptoms
in lumbar extension and often by a delay in symptoms from two to 12 hours
after the inciting episode. Initial treatment is stabilization in flexion.
Anti-inflammatories sometimes help.
When the symptoms seem to emanate from both anterior (disc) and posterior
(facets and foramen) patients cannot tolerate positions of extension or
flexion and are stabilized in neutral lumbar positions. This is a clinical
segmental global insufficiency or instability.
Herniated discs with out neurological deficits are not distinguishable
from annulus tears and are treated by extension, flexion or neutral stabilization according to the patients pain response (avoid causing symptoms).
Herniated discs with acute neurologic deficit should be treated conservatively aggressively. Epidural steroids and bed rest up to a week should be started immediately to prevent nerve damage. If there is no improvement in signs and symptoms to initial conservative care, scans should be performed and
surgery considered.
Spinal stenosis is identified clinically by intolerance of extension
and neurogenic claudication. Symptoms are usually mostly lower extremities.
Initial treatment is flexion stabilization. Epidural steroids ore often
very effective.
Spinal stenosis with acute neurologic deficit is treated as herniated
discs with neurologic deficits.
Spondylolisthesis with or without neurologic deficit is also treated
as herniated disc or spinal stenosis counter part depending on the positional
pain pattern.
Acute bowel or bladder incontinence, perineal numbness, and anal sphincter
weakness (cauda equina syndrome) are surgical emergencies which mandate
immediate work up and consultation to prevent permanent neurologic deficit.
These are rare but should not be taken lightly.
Imaging
MRI-best screening test. Doesn't show stenosis as well as CT but covers
conus to sacrum. Skip lesions are common in stenosis.
CT-radiation. Visualizes bone.
Myelography-new contrast agents relatively benign. Will occasionally
elicit a lesion that is dynamic or positional missed by other tests. Best
view of central stenosis.
Discogram-only test to show what hurts. Disco-CT scan is most sensitive
test for disc abnormalities. l/lOOO infection rate. A pre-operative test
usually for staging the scope of the procedure.
EMG-uncomfortable but very useful in following nerve damage, diagnosis
of neural abnormalities
Medications
Back problems often last a long time. Narcotics inhibit recovery in
general, make people irritable, depressed, insensitive to body mechanics,
lower pain tolerance and create occasional albatrosses. They are ok for
a week or so. The same is true for CNS depressants like Valium. Tricyclics
and heterocyclics very useful in the long run.
Non-steroidal anti-inflammatories sometimes help. Oral steroids not
as effective as injection into the site of pathology but avoid the injection.
What Makes People Better?
Time, knowledge, strength, body mechanics,
braces, anti-inflammatories, specific steroid injections, surgery
What Makes People Worse?
Ignorance, prolonged bedrest, prolonged short
acting narcotics and CNS depressants, surgery
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