75 yo Acute/Chronic LBP + Right Leg Pain RAIN 2017: Challenging - - PowerPoint PPT Presentation

2/10/2017 1

RAIN 2017: Challenging Cases John Engstrom, M.D. February 10, 2017

75 yo Acute/Chronic LBP + Right Leg Pain

• LBP and right leg-2003
• Deep, dull, aching pain from right buttock

to posterior thigh

• Worse sitting and better walking
• Chiropractor, epidural 2005 and 2008,

Pilates, narcotics, ibuprofen and gabapentin

• Working dx: sciatica, DDD
• Spontaneous fluctuation of symptoms

75 yo Acute/Chronic LBP + Right Leg Pain

• 12/13-LBP, sharp/prickly, spread R hip,

lateral thigh, lateral calf-worse over months

• Paresthesias over the sole of the R foot
• R L5 epidural block 4/14; gluteal trigger

point injection 6/14

• Neuro exam nl, except decr R knee reflex
• MRI R lat L4-5 disk protrusion, narr IVF

75 yo Acute/Chronic LBP + Left Leg Pain

• 1/16-Dull, aching LBP affecting the left

lateral thigh, calf, ankle (spared dorsal foot)

• 12/15-Severe pain getting out of bed, fell to

floor, crawled to bathroom due to pain

• Grad better; sitting best, standing worse!
• SLR and RSLR absent
• Neurologic exam and EMG normal
• Recalls childhood fall off horse; LBP 1 year

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Q1-75 yo with LBP and Leg Pain

Postural LBP (worse with flexion or extension) and leg pain is least likely to be from which of the following anatomic causes?

• A. Lumbar radiculopathy
• B. Spondylolisthesis
• C. Facet arthropathy with facet joint fluid
• D. Mild lumbar scoliosis

L u m b a r r a d i c u l

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a t h y S p

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d y l

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i s t h e s i s F a c e t a r t h r

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a t h y w i t h f . . . M i l d l u m b a r s c

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i

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9% 62% 16% 13%

Q2-75 yo with LBP and Leg Pain

What is the nl anatomic pathway for a lumbar motor nerve cell from proximal to distal?

• A. Conus to cauda equina to intervertebral foramen

(IVF) to lateral recess

• B. Conus to lateral recess to cauda to IVF
• C. Conus to cauda to lateral recess to IVF to

extraforaminal space

• D. Cauda to lateral recess to IVF

C

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u s t

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a u d a e q u i n a t

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. . C

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u s t

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a t e r a l r e c e s s t . . . C

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a u d a t

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a t e r a l . . . C a u d a t

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a t e r a l r e c e s s t

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8% 18% 74% 0%

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75 yo Acute/Chronic LBP + Leg Pain-Interpret/Localize History

• Pain quality-Not neuropathic

– Dull, deep, and achy in 2014 – Sharp and achy in 2016; not electrical/burning

• Location-Pain switched sides (R to L)

and exacerbating positions (from sitting to standing/walking)!

• Pseudodermatomal-sole of foot

paresthesias; lateral calf sparing dorsal foot

Referred Pain

• 1893 – Described by Sir Henry Head
• “Sclerotomal” pain-a correct, but clinically

impractical concept

• Splenic rupture-pain in the left shoulder
• Angina-pain or paresthesias in neck/left arm
• Vast majority of referred pain occurs in a

less predictable pattern and varies from person to person

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The Challenge of Referred Pain from the Facet Joints

• How do facet joints cause pain?

– Compress the adjacent nerve root in foramen – Inflamed joint swells with fluid (“mechanical stress”) may cause axial back pain +/- leg pain

• Can you identify the precise anatomic source of

referred pain? Usually not

• Facet blocks useful, but imperfect-no sham block
• We need an imaging ligand for pain

Q3-75 yo with LBP and Leg Pain

What would be your next management step?

• A. Refer for multidisciplinary chronic pain

management

• B. Repeat the lumbar spine MRI
• C. Perform lumbar flexion-extension x-rays
• D. Repeat the EMG

R e f e r f

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m u l t i d i s c i p l i n a r . . . R e p e a t t h e l u m b a r s p i n . . . P e r f

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m l u m b a r f l e x i

• n
• e

. . . R e p e a t t h e E M G

28% 14% 44% 13%

Extension

Flexion-Extension Spine X-rays

• To search for “dynamic instability” of spine

– Movement of one vertebral body on another that changes alignment between flexion and extension of the neck or low back – Listhesis-misalignment of vertebral bodies on another-with or without dynamic instability

• Anterolisthesis-anterior displacement
• Posterolisthesis-posterior displacement

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Circumstances in Which to Consider Flexion-Extension Spine X-rays

• Chronic LBP without radiculopathy that is

worse/better in sitting or standing positions

• Fluid in facet joints at levels commonly

prone to movement (L4-5 > L5-S1)

• Cervical stenosis without abnormal cord

signal but with myelopathic signs

• Prior MVA or traumatic spine injury

Sag T2

L4-5 Facet L4-5 Facet L4-5 synovial cyst L4-5 synovial cyst L5 root L5 root S1 root S1 root

Coronal T1 L4 L5 L4

L4-5 facets L4 lateral recess L4-5 synovial cyst L4-5 synovial cyst L4-5 lateral disc extrusion L4 root

L4 root

L4 root L5 root L5 root S1 root S1 root

Define Spondylolysis

• Spondylolysis-multiple micro fractures in

the pedicles of either L4 or L5 (usually L4)

• Congenital predisposition-6% adolescents
• Common in teenage athletes-back pain in a

teenager is a “different” entity

• Can lead to complete fractures through pars

interarticularis disconnecting the anterior vertebral body from posterior elements

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Spondylolisthesis

• Diagnosis: L4-5 spondylolisthesis with

dynamic instability and referred pain to legs

• Spondylolisthesis-Slippage of one vertebral

body on another

– Fixed-does not change on flexion-extension – Dynamic instability-movement of vertebral bodies on one another in flexion or extension – Patients may describe a specific point in time when symptoms are suddenly worse

Possible Consequences of Lumbar Spondylolisthesis

• Postural low back pain +/- leg pain
• L4 or L5 radic from nerve root tension

depending on the level/severity of the slip

• Cauda equina syndrome when segmental

movement occurs at a level of severe spinal stenosis (rare)

• Bridging osteophytes can stabilize segment

Lumbar Spondylolisthesis-Where Does the Pain Come From?

• Degenerative spondylolisthesis-Abnormal

motion/inflammation at the facet joints

• Isthmic spondylolisthesis-Abnormal motion

at fractured pars defect

• Motion of the vertebral body on the disk at

the affected segment-periosteum or annulus

• L4/L5 root stretching with radicular pain
• Combination of the above

75 yo-L4-5 Spondylolisthesis, Dynamic Instability and Pain Referred to Legs

• Spine surgery procedure

– Fusion L4-5

• Bone autograft for long term spine stabilization
• Fusion instrumentation at L4 and 5

– Posterior L4-5 laminectomy – Seen by me in follow-up 5 months later and 11 months later (last 12/16) – Pain resolved

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75 yo with LBP and Leg Pain-Patient Perspective on Functional Outcome

• “Don’t just think of me as your ‘chronic

pain patient’; know I want my life back.”

• “I can now walk/exercise as I want to.” 3

miles/day-stops from fatigue, not pain

• “I can garden; no longer all on gardener.”

Bends, prunes, up/down from ground easily

• “I am funny again.” Active social life now,

not when living with chronic pain

Take Home Points

• Location (dermatomal?), quality (burning,

electric), and position dependency of back and leg pain matter

• Consider symptomatic spondylolisthesis

when position dependency is not explained by nerve root compression

• Use flexion-extension x-rays to search for

dynamic instability of the spine