1. LOWER BACK PAIN Erestain-Garan

2. CASE Age: 45 years old CC: Lower back pain Occupation: office secretary

3. CHRONOLOGY OF EVENTS Patient lifted a box of papers. She suddenly felt a snap and pain in the LEFT LUMBAR AREA Pain was then felt in the POSTEROLATERAL aspect of the RIGHT THIGH, LEG down to the RIGHT HEEL. Patient was admitted and placed on BED REST and PELVIC TRACTION for 3 weeks with no improvement

4. NEUROLOGIC EXAMINATION FINDINGS BP: 130/80 (NORMAL or HIGH NORMAL) PR: 88 (within normal PR levels of 60-100 beats per minute) RR: 18 (within normal adult range of 12–20 breathes per minutes) T: 37°C (normal) Vital Statistics

5. NEUROLOGIC EXAMINATION FINDINGS Patient in left lateral decubitus with knee flexed Numbness: back of the right calf muscle, lateral heel, foot and toe Weakness: right plantar flexion of foot and toes Difficulty of walking on toes on the right Atrophy: Right gastrocnemius and soleus muscles Knee jerk: (++) both right and left Ankle jerk: (++) left; (absent) right Babinski: (-) both right and left The rest of the neurological exam is within normal limit

6. SALIENT FEATURES Age: 45 years old sudden snap and pain in the LEFT LUMBAR AREA Patient in left lateral decubitus with knee flexed Numbness: back of the right calf muscle, lateral heel, foot and toe Weakness: right plantar flexion of foot and toes Difficulty of walking on toes on the right Atrophy: Right gastrocnemius and soleus muscles Knee jerk: (++) both right and left Ankle jerk: (++) left; (absent) right Babinski: (-) both right and left

7. Nature of the Problem

8. Diagnosis of Spinal Injury Spinal Injury is present if: ◦ The person complains of severe pain in his or her neck or back. ◦ An injury has exerted substantial force on the back or head. ◦ The person complains of weakness, numbness or paralysis or lacks control of his or her limbs, bladder or bowel. ◦ The neck or back is twisted or positioned oddly.

9. Spinal Cord Injury Possibility of a SCI ◦ Pain ◦ Numbness ◦ Difficulty with limb movements

10. Nature of the Problem Non-traumatic Spinal Cord Injury ◦ Age ◦ Pain – left lumbar area ◦ Resulted from normal physical strain (lifting a box of papers)

11. Lumbar Spine Various forces that could be applied on the spine nerve pathways narrowing and causing nerve impingement, inflammation, and pain

12. Key muscles = level of injury C5 - Elbow flexors (biceps, brachialis) C6 - Wrist extensors (extensor carpi radialis longus and brevis) C7 - Elbow extensors (triceps) C8 - Finger flexors (flexor digitorum profundus) to the middle finger T1 - Small finger abductors (abductor digiti minimi) L2 - Hip flexors (iliopsoas) L3 - Knee extensors (quadriceps) L4 - Ankle dorsiflexors (tibialis anterior) L5 - Long toe extensors (extensors hallucis longus) S1 - Ankle plantar flexors (gastrocnemius, soleus)

13. Numbness in the back of the R calf muscle (S1-S2) Atrophy of R gastrocnemius and soleus Numbness in the lateral heel (S1) Numbness in the foot and toe (L4-L5, S1-S2)

14. Numbness in the foot and toe (L4-L5, S1-S2) Weakness of the R plantar flexion of foot and toes Difficulty walking on toes on the R

15. What is the difference between a radicular and myelopathic manifestations and what is the significance of each in relation to the signs and symptoms and clinical management?

16. Radiculopathy ◦ Pain and numbness involving the degeneration or inflammation of the spinal nerve roots ◦ usually without objective signs of neurologic dysfunction Myelopathy ◦ involves degeneration or any disease of the spinal cord

17. In Radiculopathy, compression of single root may not cause significant sensory loss (due to overlap of dermatomes in the body) The main symptom: sharp, burning pain or “shooting pains”. Follow a dermatomal distribution, accompanied by paresthesias, and loss of muscle power innervated by the root.

18. Symptoms of myelopathy would usually depend on the cause and severity of the condition Trauma, herniated disc, OA of the spine, and tumors cause myelopathy Symptoms: pain, loss of sensation or movement, decreased spinal range of motion, weakness, and deformity

19. Upon PE, clonus would usually indicate an UMN disorder

20. Significance From the signs and symptoms along with the PE results, we can achieve the correct diagnosis of our patient. The persisting signs and symptoms would help us determine the appropriate mangement.

21. How does one localize the lesion based on anatomical diagnosis and other ancillary procedures?

22. Lower Motor Neuron Lesion In the Case: ◦ Patient has the following LMN symptoms:  (+) Atrophy of right gastrocnemius muscle and soleus muscles  (+) Areflexia in Right ankle jerk  (-) Babinski bilaterally

23. Peripheral Nerve Lesion WEAKNESSDistal, symmetrical OBJECTIVE/SENSORY DEFICITSDistal, symmetical AUTONOMIC DISTURBANCESMay be present REFLEXESAreflexia

24. Lumbar Radiculopathy L5-S1 ◦ In the patient: Numbness in the back of the right calf muscle, lateral heel, foot and toe Weakness of the right plantar flexion of foot and toes Difficulty walking on toes on the right Right ankle jerk absent

25. Weakness of the right plantar flexion of foot and toes

26. Numbness in back of the right calf muscle, lateral heel, foot and toe

27. Both knee jerks are (++) Right ankle jerk absent, left ankle jerk (++) Numbness in lateral heel, foot and toe

28. Diagnosis If no improvement in symptoms have occurred in six weeks or red flags are present, imaging is appropriate. CT scan  used to evaluate the bony anatomy in the lumbar spine, which can show how much space is available for the nerve roots. ◦ NEUROFORAMEN- vulnerable point of compression MRI scan  useful for determining where the nerve roots are being compressed ; shows the details of soft-tissue structures, like nerves and discs.

29. Diagnosis MR neurography ◦ modified MRI technique providing better pictures of the spinal nerves and the effect of compression on these nerves. ◦ may help in diagnosis and treatment of sciatica/lumbar radiculopathy.

30. Treatment goals of treatment : ◦ relieve pain ◦ prevent or reduce stress on the disc ◦ maintain normal function ranges from conservative therapies to surgical interventions

31. Conservative Treatment Most treatment plans involve a combination of self-administered treatments, medications, and therapeutic measures. Self-administered treatments include the following: – Learn/practice proper posture and body mechanics – Rest and restrict activities – Limited bed rest to take pressure off the spine – Mild activity (exercise) such as walking, biking, and swimming – Apply cold and/or hot packs – Wear a brace for support (may not be helpful in all cases)

32. Conservative Treatment Therapeutic treatments for DDD include the following: ◦ Chiropractic treatment to manipulate the spine ◦ Acupuncture to relieve pain ◦ Massage therapy to relieve muscle spasms and tension ◦ Physical therapy to improve function and increase flexibility and strength

33. Medications Are used to supplement conservative therapy. – Non-steroidal anti-inflammatory drugs (NSAIDs; e.g., aspirin, ibuprofen, naproxen) – Pain relievers (e.g., acetaminophen) – Muscle relaxants – Spinal injections (anesthetics or corticosteroids) – Antidepressants – Sleep aids Other non-surgical treatments – ultrasound therapy : uses sound waves to warm the area, increase blood flow, and relieve discomfort – transcutaneous electrical nerve stimulation (TENS): uses electrical stimulation of the nerve to interrupt pain signals

34. Surgical Primary reasons for surgery are to: ◦ relieve pressure on a nerve root or the spinal cord ◦ stabilize an unstable or painful vertebral segment ◦ prevent or limit radiculopathy (nerve damage) ◦ reduce deformity or curvature of the spine (e.g., scoliosis)

35. Surgical Discectomy and fusion – involves removing the damaged intervertebral disc and replacing it with a piece of bone or another material – this replacement fuses with the adjacent vertebrae Corpectomy – a section of the vertebrae and discs is removed to create more space for the remainder of the spine – A bone graft and/or metal plate with screws – attached to stabilize the spine Facetectomy, laminotomy, and spinal laminectomy – procedures that involve removing a portion of the bony structure of the spine to relieve pressure on the nerve roots – Foraminotomy and laminoplasty can be used to enlarge areas of the spinal column to make more room for the nerves and spinal cord

36. Surgical Micro-discectomy – removes a disc through a very small incision using a microscope. Percutaneous disc decompression – reduces or eliminates a small portion of the bulging disc through a needle inserted into the disc, minimally invasive Spinal decompression – A non-invasive procedure that enlarges the Intra Vertebral Foramen (IVF) by aiding in the rehydration of the spinal discs. Spinal laminectomy – relieves pressure of spinal stenosis – part of the lamina is removed or trimmed to widen the spinal canal and create more space for the spinal nerves.

37. Indications for Surgery

38. Surgery may be recommended: 1. If the conservative treatment options do not provide relief within two to three months. 2. If leg or back pain limits normal activity 3. If there is weakness or numbness in the legs 4. If it is difficult to walk or stand, or if medication or physical therapy are ineffective, surgery may be necessary, most often spinal fusion.

39. Lumbar surgery ◦ indicated in patients with severe spinal stenosis, in those with intractable pain, and in patients in whom an appropriate 6- to 12-month nonoperative course of treatment fails. In elective cases, other conservative modalities should have been tried and observed to fail. In cases of cervical disk disease with radiculopathy ◦ indications for surgical treatment are intractable pain, progressive motor or sensory deficit, or symptoms refractory in a reasonable period of nonoperative therapy In cases of cervical disk disease with myelopathy ◦ early surgery to decompress the spinal cord is recommended to arrest progression if the clinical and radiographic changes are well correlated

40. Thank You!

41. References: ◦ http://www.cedars-sinai.edu/515.html http://www.cedars-sinai.edu/515.html ◦ http://www.cedars-sinai.edu/889.html http://www.cedars-sinai.edu/889.html ◦ http://www.cedars-sinai.edu/5757.html http://www.cedars-sinai.edu/5757.html ◦ http://www.neurologychannel.com/degenerative-disc- disease/treatment.shtml http://www.neurologychannel.com/degenerative-disc- disease/treatment.shtml ◦ http://www.dcmsonline.org/jax- medicine/1999journals/april99/degenerative.htm http://www.dcmsonline.org/jax- medicine/1999journals/april99/degenerative.htm ◦ http://emedicine.medscape.com/article/1265453- treatment http://emedicine.medscape.com/article/1265453- treatment