CLINICAL FEATURES

Disc disease (herniation and/or degeneration) may result in several overlapping clinical syndromes: (1) mild herniation without nerve root compression; (2) herniation with nerve root compression; (3) cauda equina syndrome; (4) chronic degenerative disease with or without leg symptoms; and (5) spinal stenosis.

The onset of symptoms from disc herniation is variable. One specific traumatic episode may produce symptoms, but because of the progressive nature of the disease process in the disc, the symptoms usually develop gradually as the disc slowly changes. (How much herniation is required to produce symptoms is unknown, but “bulging” of the disc commonly reported on magnetic resonance imaging [MRI] studies is probably not sufficient.) The most common complaint is low back pain, which is often deep and aching in nature. This pain, which is sometimes referred to as axial, is usually one sided and may be aggravated by activity and relieved by rest. Coughing, sneezing, or other actions that increase the stress on the disc tend to intensify the pain. The back pain is often localized near the disc and may be referred to the iliac crest or buttock. It is may be the result of stretching of the anulus by the expanding, protruding disc. Radicular pain occurs when the disc protrudes far enough to press on the adjacent nerve root. Nerve root pain is usually quite intense. Often, if the disc herniates completely (extrudes), the low back pain may be relieved because the tension on the anulus is gone, but the leg pain intensifies.

Axial low back pain may occur in combination with radiating pain, or the two pain patterns may occur separately. Radicular pain characteristically spreads over the buttock and passes down the posterior or posterolateral aspect of the thigh and calf and may even spread onto the foot. Both types of pain usually improve with bed rest. If little or no relief of pain occurs with rest, inorganic causes should be considered. Relentless pain that is not relieved or may even be aggravated by recumbency suggests a spinal cord tumor.

Paresthesias in the form of numbness and tingling are common and are usually more marked in the distal portion of the extremity. They may follow a specific dermatome pattern (Fig. 8-8).

FIG. 8-8 Dermatomes of the lower extremity.

Examination often reveals restriction of low back motion. Bending toward the affected side frequently exacerbates the pain. Variable degrees of local tenderness and muscle guarding are present. In an attempt to relieve pressure or tension on the nerve root, the patient may list or bend away from the painful side and stand with the affected hip and knee slightly flexed. A characteristic clinical picture may be present, depending on the level of nerve root involvement (Table 8-2). The sensory examination may reveal diminished sensation along the affected dermatome, although the sensory examination is usually not very helpful. The various tests measuring sciatic nerve root tension are frequently positive if herniation is causing nerve compression (Fig. 8-9).

Table 8-2 Clinical Features of Common Lumbar Disc Syndromes

FIG. 8-9 Testing for nerve root tension. The foot is slowly raised, keeping the knee straight, until sciatic pain is produced. A positive test includes the following: (1) pain produced before 70 degrees is reached, (2) aggravation of the pain by dorsiflexion of the ankle, and (3) relief of the pain by flexion of the knee. If the patient can extend the leg to 90 degrees while sitting but the same test is impossible in the supine position, pain magnification should be suspected. If raising the leg on the contralateral side reproduces pain in the affected leg, disc herniation should be strongly suspected.

SPECIAL STUDIES

The diagnosis usually becomes apparent on the basis of the history and physical examination. Early disc herniation may be difficult to differentiate from other causes of back pain, however.

FIG. 8-10 Abnormal lumbar myelogram revealing a large extradural defect (arrow) in the dye column that is consistent with disc herniation.

NOTE: The number of symptomatic conditions discovered by special studies but not suspected clinically is very small. Tests such as MRI and EMG should only be performed as adjuncts to the clinical assessment.

TREATMENT

The initial treatment is always conservative, and the majority of patients respond well. Treatment is based on the symptoms of the patient and not on any imaging study. Extended periods of inactivity are no longer recommended for most low back disorders, but a short period of bed rest (5 to 10 days) may be very helpful in the treatment of acute disc herniation, mainly if radicular leg pain caused by nerve root compression is present. This is followed by a careful exercise program. While the patient is in bed, the hips and knees are kept moderately flexed. Lying on the abdomen, which increases the lumbar lordosis, is avoided. Hip flexion and pelvic tilt exercises are begun within the limits of pain (Fig. 8-11). Nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, and moist heat are used as necessary. Narcotics may even be required in cases of nerve root compression and intense leg pain. If improvement occurs, which it does in the majority of cases, gradual resumption of activity is allowed, and the exercise program is expanded. Physical therapy is often useful, mainly for the exercise program. Modalities such as deep heat and massage can be added for their “hands-on” appeal. A lumbosacral corset may be temporarily used. (There is no evidence that continued use of any brace promotes back weakness, however, especially if the patient adheres to an exercise program.) Recurrences are prevented by a proper exercise program and the avoidance of stress to the lower part of the back (Fig. 8-12).

FIG. 8-11 Low back exercises. A, Pelvic tilt performed to decrease the lumbar lordosis and raise the anterior aspect of the pelvis. The small of the back is pressed to the floor, and the abdominal and buttock muscles are tightened. B, Hip flexion, performed to stretch the tight posterior spinal musculature and unload the posterior disc. Each knee is drawn up and pulled firmly to the chest several times and held for 10 to 20 seconds. The exercise is then repeated with both knees. After the acute pain has subsided, the remainder of the exercises are performed. C, Hamstring stretching exercises. D, Hip flexor stretching exercises. E, Quadriceps strengthening and heel cord stretching exercise. F, Abdominal strengthening exercise (sit-ups, which may be partial). All exercises are performed on a carpeted floor and should be repeated in sets of 5 to 10 at least three times daily.

FIG. 8-12 General postural instructions. Patients should be instructed to do the following. A, Bend the knees and hips, and keep the back straight when lifting. B, Hold objects close to the body when carrying. C, Place one foot on a stool when standing. D, Keep the knees higher than the hips when sitting, and keep the back straight when standing by “tucking in” the abdomen and tightening the buttocks to decrease swayback. In addition, patients should avoid high-heeled shoes and sleeping on the abdomen, activities that increase lordosis.

Caudal or epidural cortisone injections are often very helpful. They may help relieve residual radicular pain. They tend not to relieve axial spine pain and may have no effect on acute leg pain if there is persistent nerve root compression from herniated or extruded disc material.

The prognosis for full recovery is excellent, and the majority of patients with disc herniation will improve with conservative treatment. Mild axial spine pain may recur on a sporadic basis indefinitely, however. Most of the time, this can be managed with mild analgesics and physical therapy. Motivation and reassurance are important. Keeping the patient active and comfortable can be difficult and challenging. What happens to the disc material that has herniated is unknown. It is theorized that it may act as a foreign body and be invaded by granulation tissue. Ultimately, the material may be absorbed or transformed into scar tissue. Larger herniations may actually regress the most.

Disc removal is reserved for those patients with major or progressing neurologic deficits or those with intractable leg pain who fail to respond to conservative management for at least 6 weeks. Of those patients with radicular leg pain documented by radiographic studies, fewer than 5% require surgery to relieve their symptoms. The patient must understand that disc removal is performed to relieve leg pain and that it has no effect on axial spine pain.

There are several ways of removing disc tissue, but the results of surgery are influenced more by patient selection that by the manner that the disc is removed. With a positive history, physical findings, myelography (or similar study), and EMG, there is a 90% to 95% success rate for surgery. In the absence of one or more of these, the cure rate for disc removal by any means declines considerably. Patients must also be cautioned that although their leg pain will usually disappear postoperatively, some mild intermittent low back pain may persist.

SUMMARY

Surgery is effective in most cases, but selection is the key. When advising treatment, the following well-known facts should always be kept in mind:

CLINICAL FEATURES

The history is highly suggestive. Neurogenic claudication is a hallmark symptom. Low back pain, motor weakness, leg cramping (pseudoclaudication), and a sensation of “poor circulation” in the extremities are typical. The patient is usually older than 50 years of age. The symptoms are characteristically aggravated by walking and by extension of the lumbar spine. Improvement usually occurs with rest or flexion of the back. While grocery shopping, the patient often leans forward onto the cart to relieve the leg pain. These symptoms are often misinterpreted as being vascular in origin. Vascular symptoms will improve with rest, however, whether the patient is standing or sitting, but the patient with neurogenic claudication usually requires sitting because the forward flexed position increases the cross-sectional area of the bony canal, thereby relieving the symptoms. Sphincter disturbances and muscle atrophy rarely may be present. Physical findings typical of disc herniation are usually absent. Neurologic findings are also frequently minimal, and results of a straight-leg–raising test are usually normal. Pain on extension of the lumbar spine may be severe. The vascular examination is usually normal, but because vascular disease and stenosis occur in similar age groups and can produce similar symptoms, vascular studies may be necessary in some cases to differentiate the two conditions.

Roentgenographic examination of the lumbar spine usually reveals degenerative changes throughout the lower part of the back. EMG and myelography may help localize the disorder, and CT scanning is frequently diagnostic (Fig. 8-14). MRI is also helpful.

FIG. 8-14 Normal (A) and abnormal (B) computed tomographic scans of the lumbar spine. Marked narrowing (arrow) is present in B because of hypertrophic spurring.

TREATMENT

Nonsurgical treatment is the mainstay of care for the patient with degenerative stenosis. Treatment is directed at reducing the lumbar lordosis and promoting lumbosacral flexion. A light corset is sometimes beneficial. Anti-inflammatory medication may be prescribed, but unfortunately, the older patient who develops this conditon often cannot tolerate NSAIDs, and simple analgesics may be more suitable. Hip flexion and abdominal strengthening exercises may also be helpful. Periodic epidural pain blocks can relieve the leg symptoms.

The long-term prognosis is generally good. Serious neurologic sequelae are unusual. Patients who fail to improve with nonsurgical care may need to be referred to a surgeon who specializes in spine disorders.

CLINICAL FEATURES

Spondylolysis may be symptomatic even without spondylolisthesis, and both conditions may be associated with lumbar disc herniation. The disorder is often asymptomatic, however, and is frequently discovered incidentally in adults on roentgenograms taken for other purposes. When it is seen on roentgenograms taken as a part of a routine evaluation for back pain, it is often difficult to determine whether or not it is playing any role in the patient’s complaints.

Symptoms from spondylolisthesis may begin gradually in the second or third decade. Low back pain, sometimes radiating into the buttocks, occurs with activity and is relieved by rest. If the lesion is acute, symptoms of nerve root irritation may also be present, along with radiation of the pain into the extremities. These symptoms often progress in severity, especially in the teenager.

Examination may reveal guarding of the lower part of the back and “spasm” of the paraspinal muscles, especially in the adolescent. Many children have no pain, however, but present with postural deformity or an abnormal gait pattern resulting from hamstring tightness. With moderate forward slippage, the lumbar lordosis appears increased, and the buttocks may appear more prominent. A palpable “step-off” in the spinous processes of the lumbar spine may be present. There may be tenderness in the affected area and hamstring tightness. Neurologic deficits are rare.

Roentgenograms reveal the typical findings of a defect in the pars interarticularis on both sides, which may be accompanied by forward slippage (Fig. 8-17). Unilateral defects are unusual. The classic findings of periosteal new bone present in stress fractures of long bones are rarely seen in the spine. A bone scan may be positive if the lesion is “acute” in the adolescent. MRI may be indicated in cases of negative bone scan to rule out other causes of pain. CT is also helpful to assess healing potential.

FIG. 8-17 Spondylolisthesis of the lumbosacral junction.

TREATMENT

In the adolescent, the goal of treatment is to achieve healing of the stress fracture and if that is not possible, to have a painless nonunion. It is helpful to determine if the lesion is simply a stress reaction that has not yet progressed to a complete fracture. It is also important to assess healing and the status of the lesion, whether acute or chronic. If the lesion is acute and no slip is present, the patient may benefit from prolonged bracing and restricted activities for several months in an attempt to encourage bony healing before nonunion can develop, which could allow slippage to occur. If the scan is cold and chronic with several millimeters of separation, then the lesion probably will never heal, especially if healing has not occurred by 6 months. In this case, such extreme limitations on the patient’s activities would not be helpful. Then, the treatment is similar to that for an adult.

Management in the adult is usually conservative and consists of rest, a careful exercise program, hamstring stretching, weight loss, anti-inflammatory medication, and the intermittent use of a lumbosacral orthosis. A change in occupation or work habits is sometimes indicated. The spondylolisthesis may increase in degree, but this is a gradual process and usually ceases by maturity. Further slippage in adulthood is rare. Progressive symptoms or intractable pain occasionally warrants surgical intervention. Decompression with spinal fusion is usually performed.

EVALUATION

The treating physician is often required to give an opinion regarding the etiology of musculoskeletal conditions involved in workers’ compensation, so obtaining an accurate physical examination and history is especially important to determine whether an injury actually occurred or if the pain simply developed during or after an activity. If pain began some time later, it should be recorded how much time passed between the event or work activity and the onset of symptoms. The pain may be referred to one or both legs, but it is usually not truly radicular in nature. Frequently, a description of the location and nature of the pain changes slightly from visit to visit.

Physical findings are often nonspecific. There is usually generalized low back tenderness and diminished range of motion. Sometimes, the physical findings are “nonanatomic” in nature. Waddell signs are often cited when nonorganic physical findings are present (Table 8-3). There is usually no neurologic deficit, and sciatic tension tests are generally normal but may be difficult to assess.

Table 8-3 Waddell Tests

SPECIAL STUDIES

All of the anatomic structures of the lower part of the back (discs, ligaments, facet joints, bone, and muscle) can be the source of pain. The intervertebral disc is thought by many to be the source of most low back pain. Unfortunately, as many as 35% of asymptomatic adults will have abnormal findings on myelography, CT, or MRI that are usually related to the disc. This makes evaluation of this problem difficult, and it is felt by many that in the majority of cases, the exact underlying pathology probably cannot be determined and the condition is simply called “idiopathic.” Initially, a routine roentgenographic examination should be performed in 2 to 4 weeks if the patient does not improve, mainly to rule out any serious disorder. Further studies (EMG, CT, MRI, bone scan, myelography) should be performed only as adjuncts to the physical examination and history. The yield of clinically useful information from these studies is often poor. Subjecting patients to further extensive testing in a search for the exact etiology of their pain is likely to be futile, sometimes painful, and always costly. Diagnosing a spinal disorder solely on the basis of any of these tests should be avoided. It is rare that these special tests clearly demonstrate a source for the pain when it is not suspected clinically. In addition, any treatment (e.g., surgery) based solely on a special study will often fail. In general, myelography and other special studies should be used only under the following circumstances: (1) if surgical disc removal is contemplated for intractable leg pain or a serious neurologic deficit, or (2) if other serious spinal abnormality is suspected.

TREATMENT AND PROGNOSIS

Considerable controversy exists regarding the treatment of this problem. Historically, the disorder has always been resistant to traditional medical care. Thus, there has been a proliferation of rehabilitation services, pain centers, work-hardening programs, surgical procedures, chiropractic care, and physical therapy services. Patients often prefer this type of “hands-on” treatment, but no scientific proof exists that any of these treatments is any better than nature’s own. And although orthopedic and neurologic surgeons are commonly called on to assess and treat this condition, in fewer than 1% of these cases is surgery ever indicated (usually for leg pain associated with severe disc herniation), and not for at least 6 to 8 weeks. Surgery may even become a negative factor for returning the patient to work in that it gives validity to the injury.

Fortunately, the natural history of most back problems is that they improve and the end result of conservative management is usually good. Unfortunately, the longer the patient is away from work with benign low back pain, the less likely it is that the patient will ever return to gainful employment, and after 6 months of not working, the chance that the patient will return to any work is minimal. Thus, for a number of reasons, the trend for managing this condition has changed. There has been a de-emphasis on the initial rest period and more encouragement to early exercise and returning to work on a limited basis. This trend has developed largely because of the low success rate with prolonged bed rest and the belief that it causes a deterioration of the musculoskeletal and cardiopulmonary systems (deconditioning). It has also been shown that patients who begin exercise programs quickly after minor low back injuries have less pain and are disabled for shorter periods of time. (Only the patient with nerve root impingement because of disc herniation may require more rest.) The following approach may be helpful:

It is important for the treating physician to remain the patient’s advocate but to be objective at the same time, a situation that often results in conflict. Patients should be made to understand that the pain may recur if they resume light work, but it is usually not as severe as it was initially and does not mean any damage is occurring. It should not require further time off from work. The patient should continue the exercise program and practice good body mechanics. (A formal education program may be necessary.) Active participation by the patient and compliance are extremely important.

If no improvement has occurred after 4 to 6 weeks, referral to a specialist is indicated. Psychosocial factors and work-related conditions may also need investigation. The attitude of the patient to the job and involvement of the employer also play important roles in the length of disability. Workers who like their jobs and employers who promote a good working environment are more likely to have a mutually satisfactory relationship.

CLINICAL FEATURES

Only axial dorsal spine pain occurs in most cases. With central herniation and myelopathy, however, gradually increasing motor weakness in the lower extremities becomes apparent. Sphincter control may be lost, and diffuse numbness is common. Sensory testing may help determine the level of involvement. Examination usually reveals limited motion in the dorsal spine. Major neurologic deficits may be present in the lower extremities (spasticity, clonus). Roentgenographic examination often reveals calcification, narrowing, and spondylosis in the dorsal spine. Myelography may reveal a complete block in central lesions. MRI is often needed.

TREATMENT

Treatment is symptomatic for the typical case, with thoracic pain caused by degenerative disc disease. Symptoms in most cases with no cord compression resolve without sequelae. The treatment is surgical in those with cord compression caused by disc rupture, and immediate referral is indicated. Residual neurologic deficits are not unusual, in spite of surgical decompression.

CLINICAL FEATURES OF IDIOPATHIC SCOLIOSIS

Genetic or idiopathic scoliosis usually appears clinically between the ages of 10 to 13 years, but may be seen at any age. By definition, the curve must be greater than 10 degrees. (This has been used historically because 10 degrees is the limit that can be detected by clinical examination.) It is six times more common in females, and serious curvatures are also more frequent in females. Right thoracic curves are the most common. In young people, the disease is usually asymptomatic, and subjective complaints are absent. (Pain should suggest tumor or other disorder.) Many cases are diagnosed by nurses in screening clinics or by other family members. Idiopathic scoliosis is sometimes classified according to age of onset (infantile, juvenile, adolescent) or by curve pattern. The adolescent type is most common. Prevalence is 1% to 3% of the general population.

The diagnosis is usually made on routine physical examination. Attention should be focused on the problem in all children, but especially in those between the ages of 10 to 14 years, when spinal growth is most rapid. For the examination, the patient should be undressed to the waist or wear a bathing suit, and a routine should be followed. The shoulders and iliac crests are inspected to determine whether they are level. The scapulae, rib cage, and flanks are then observed for symmetry. The spinous processes are palpated to determine their alignment. The patient is then asked to bend symmetrically forward at the waist with the arms hanging free (Fig. 8-19). Observation from the back or front will detect the spinal rotation in the form of a rib hump or abnormal paraspinal muscular prominence. Height measurements are taken initially and at all follow-up visits to gauge the growth rate of the patient and assess the risk of rapid progression of the curve. Additional data should be obtained regarding skeletal and sexual maturity (onset of menses, etc.).

FIG. 8-19 A, Scoliosis with rib prominence resulting from vertebral rotation is best exhibited on forward bending (the Adams position). B, Cross-section of the chest showing rib distortion caused by vertebral rotation.

The diagnosis is confirmed, and the degree of curvature is measured by a standing roentgenogram of the spine (Fig. 8-20). There is no other method of determining the severity of the curve, and a patient should never leave the office without an accurate roentgenographic measurement of the curvature. The roentgenogram may have to be repeated at intervals to determine whether or not the curve is progressive. Breasts and gonads should be shielded when films are done. The degree of skeletal maturity can be determined by assessing the status of the iliac apophysis using the Risser sign (Fig. 8-21).

FIG. 8-20 Cobb method of measuring the severity of a curve. The upper and lower end vertebrae are identified. The upper end vertebra is the highest one whose superior border converges toward the concavity of the curve, and the lower end vertebra is the one whose inferior border converges toward the concavity. Lines are drawn along these borders, and the curve is measured directly (a) or geometrically (b).

FIG. 8-21

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