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Published on : Dec 06, 2013
Views : 2034 | Downloads : 1

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Download Low Back Pain Presentation Transcript

Slide 1 -

Sciatica/HNP Thomas M. Howard, MD Sports Medicine

Slide 2 -

HNP-Epidemiology 30-40 yo >95% @ L4-5 and L5-S1 75% resolve in 6 months 5-10% require surgery

Slide 3 -

Joints zygoapophyseal (facets) synovial joint (cartilage, capsule, synovium) limit extension/flexion Disc nucleus pulposus two end plates annulus fibrosis laminated collagen fibers 65o orientation

Slide 4 -

L4 Motor- quad and tibialis anterior Sensory- medial foot DTR- patellar

Slide 5 -

L5 Motor- extensor hallicus longus (EHL) Sensory- dorsal foot DTR- none

Slide 6 -

S1 Motor- foot plantar flexion and eversion Sensory- lateral foot DTR- achilles

Slide 7 -

HNP-Pain Torn annular fibers of disc Chemical and mechanical irritation of: spinal root soft tissues (posterior longitudinal ligament)

Slide 8 -

Annular Tear Lumbar strain Locked in flexion without neuro sx

Slide 9 -

Sciatic Neuropathy HNP Trauma blunt- fall or contusion penetrating- injection, fracture, stab traction- hip surgery Peripheral Compression wallet sciatica piriformis syndrome (myofacsial)

Slide 10 -

History

Slide 11 -

Onset Usually spontaneous and without discrete event Discrete events lift cough/sneeze prolonged drive flexion/flexion with twist

Slide 12 -

Pain with… Prone position Facet, Lat HNP, systemic Sitting Paramedian HNP, annular tear Standing Lateral HNP, central stenosis, facet syndrome Walking Central stenosis

Slide 13 -

Other Symptoms Cough/valsalva exacerbation Distal neuro sx - weakness/paresthesia Bowel/bladder sx

Slide 14 -

Red Flags

Slide 15 -

Differential Diagnosis

Slide 16 -

Examination Walk Standing Sitting Supine

Slide 17 -

Walking Gait length of stride arm swing trunk motion ?pelvic tilt

Slide 18 -

Standing - Range of Motion FF ~90o (reversal of lumbar lordosis with FF) Ext ~15-20o Side bend ~ 45o Trunk rotation

Slide 19 -

Standing - Other Tests Single leg extension Gastroc strength Squat Standing single-leg balance (nl 15-30 sec)

Slide 20 -

Supine SLR (Lasegue Test) Passive hip flexion Modified Thomas Test (Quad & Hip flexor flexibility) FABER (Patrick Test) SI Compression Test

Slide 21 -

Supine Rectal tone Anal wink Cremasteric reflex

Slide 22 -

Supine - Palpation Spinous processes Dorsal lumbar fascia/soft tissues Sacral notch tenderness

Slide 23 -

Radiographs Early if ominous signs - fever, night pain, age >60, h/o Ca, wt loss, trauma Symptoms > 1 month

Slide 24 -

MRI/CT Not needed to diagnose HNP 30% asx patients will have an abn MRI Order if hx/exam confusing Roadmap for surgeon MRI more costly, increased time to scan, problem with claustrophobic patients

Slide 25 -

EMG/NCV R/O peripheral neuropathy Localize nerve injury Correlate with radiographic changes Order after 4 weeks of symptoms

Slide 26 -

Lab Studies Generally not necessary

Slide 27 -

Acute Management Relative rest no more than 48 hrs bedrest Educate patient body mechanics natural history of the condition Modalities Ice Heat Ultrasound Electric Stimulation

Slide 28 -

Acute Management Medications Pain control Tylenol/NSAID’s minimize narcotic use Muscle relaxers use Valium for short term (1-2 days) Corticosteroids 2mg/Kg burst for 5-7 days

Slide 29 -

Acute Management Exercises Extension biased discogenic flexion biased posterior element pain

Slide 30 -

Physical therapy Bracing Traction Education Modalities Tissue flexibility and segmental motion Strengthening and postural control Home program instruction

Slide 31 -

Traction May decrease disc pressure 20-30% May allow separation of vertebrae to decrease nerve root compression

Slide 32 -

Subacute Management Continue patient education Activity & Conditioning walking Stretching - HS, hip extensors, erector spinae Strengthening - abs, erector spinae Mechanics - lifting technique, sport, ... Avoid prolonged sitting/standing recurrent bending twisting

Slide 33 -

Epidural Steroid Injection (ESI) Local anti-inflammatory Performed by experienced anesthesiologist May buy time for the pt with marginal surgical indications

Slide 34 -

Referral HNP (> 8 weeks) Ominous signs/sx - fever, weakness, bowel/bladder dysfunction Progressive neuro deficit or flaccid paralysis

Slide 35 -

Caveats of Management Adequate/complete initial evaluation Follow-up evaluations 1-3 days for acute pain 4-6 weeks for chronic pain Activity as tolerated Survey for Red Flags

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