Orthopaedic Approach to Back Pain. Seth Cheatham, MD

Size: px

Start display at page:

Download "Orthopaedic Approach to Back Pain. Seth Cheatham, MD"

Arlene Kelly
8 years ago
Views:

1 Orthopaedic Approach to Back Pain Seth Cheatham, MD 262

2 Seth A. Cheatham, MD VCU Sports Medicine I have no financial disclosures. Focus on clinical situations where a referral to an orthopaedic surgeon is appropriate for further management of low back pain in the athlete Will highlight the following conditions: Disk Herniation Degenerative Disk Disease Spondylolysis Spondylolisthesis Neoplasms 263

appropriate for further management of low back pain in the athlete Will highlight the

3 30% of athletes will report back pain Rate may be sports specific: 11% of gymnasts 50% of football linemen Type of injury may be sports specific: Herniated disks football players, weight lifters Spondylolysis gymnasts Traumatic lumbar spine injuries wrestlers, hockey players More commonly due to repetitive microtrauma Most patients respond well to rest, medication, PT Surgery may be considered in selective circumstances Prior back injury (most significant) Decreased range of motion Poor conditioning Excessive/repetitive loading Improper play techniques Abrupt increases in training 264

to repetitive microtrauma Most patients respond well to rest, medication, PT Surgery may be considered in selective circumstances Prior back injury

4 Results when an annular injury allows nucleus pulposus material to escape into the surrounding epidural space Incidence is unknown Initially, can be associated with low back pain Related to traumatic injury of annulus May progress to radicular symptoms Classically, presents with radicular symptoms Pain worse with flexion, valsava maneuver; improves when laying supine Most common levels are L4/5 and L5/S1 (90%) L5 root weakness of ankle dorsiflexion, great toe dorsiflexion. Sensory changes over lateral aspect of leg and dorsum of foot. S1 root weakness in ankle eversion/plantarflexion. Sensory changes over lateral aspect of foot. Decrease in achilles reflex. Most specific test straight leg raise Cauda Equina Syndrome: (surgical emergency) Saddle paresthesias Bowel/bladder incontinence Back pain (+/ ) Occasional radiculopathy MRI is study of choice 265

and L5/S1 (90%) L5 root weakness of ankle dorsiflexion, great toe dorsiflexion. Sensory changes over lateral aspect of leg and dorsum of foot. S1 root weakness in ankle eversion/plantarflexion.

5 Initial tx consists of: Rest NSAID s Medrol Dose Pack PT emphasis on trunk/core strengthening If radicular symptoms continue may consider a selective nerve root block When such injections are not tolerated or symptoms persist, lumbar discectomy may be considered. Low back pain w/ or w/o referred pain Pain increases with movements that stress the disk (i.e. flexion) and improves with extension Plain x rays may show loss of disk space height MRI loss of disk hydration, end plate changes 266

6 Treatment is primarily non surgical due to self limited nature of disease Rest from practice/competition NSAID s PT trunk/core strengthening Lumbosacral corsets or orthoses not supported by literature Spinal fusion is poor option in athletes Results unpredictable Lengthy post op course No data regarding return to sports Role for disk replacement? concern over demands Defect of the pars interarticularis Typically results from repetitive extension activities Gymnasts & football linemen Some of these patients may have concomitant spondylolisthesis Forward slipping of one vertebra on another Spondylolytic spondylolisthesis is most common type seen in athletes 267

7 Present with low back pain worse with activity May have stiff legged gate due to hamstring spasm and limitation in flexion May have tenderness in paraspinal musculature May have radicular symptoms (especially at L5) Standing AP/Lateral/Oblique views of lumbar spine can be obtained Look for collar around neck of Scotty dog Flexion/Extension films can look for instability Additional imaging can be considered: CT MRI SPECT (most sensitive) 268

L5) Standing AP/Lateral/Oblique views of lumbar spine can be obtained Look for collar around neck of Scotty

8 Initial treatment consists of bracing and restriction of activities Bracing 6 12 weeks TLSO w/ or w/o leg extension Goal is to alleviate symptoms, not necessarily go on to union of stress fx PT should focus on core strengthening and ROM to L spine/le High percentage of patients able to return to activity with non surgical tx. Indications for surgery: Progressive spondylolisthesis > grade 3 spondylolisthesis Persistent back pain Neurologic deficits May attempt surgical repair of spondylolytic defect Fusion may be indicated if spondylolisthesis or disk degeneration present No good data reviewing outcomes of these procedures in athletic population 269

Indications for surgery: Progressive spondylolisthesis > grade 3 spondylolisthesis Persistent back pain Neurologic deficits May attempt surgical repair of

9 Although uncommon, different tumors can cause back pain in the young, athletic population Most commonly: Osteoid Osteomas Osteoblastomas Involve pedicle or lamina Pain more pronounced at night Respond well to NSAID s CT scan Treatment Excision Radiofrequency ablation Also found in posterior aspect of spine Larger than osteoid osteomas (>1.5cm) Neurologic risk greater 40% of patients will have scoliosis Treatment is operative excision 270

s CT scan Treatment Excision Radiofrequency ablation Also found in posterior aspect of spine Larger than

10 271

Return to same game if sx s resolve within 15 minutes. Return to next game if sx s resolve within one week Return to Competition

Return to same game if sx s resolve within 15 minutes. Return to next game if sx s resolve within one week Return to Competition Assessment Skills of the Spine on the Field and in the Clinic Ron Burke, MD Cervical Spine Injuries Sprains and strains Stingers Transient quadriparesis Cervical Spine Injuries Result in critical loss