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