Conservative Management of Spinal Conditions

Conservative Management of Spinal Conditions

• Low back pain (LBP) affects a majority of patients who aren't surgical candidates.
• A trial of conservative management is often preferred over surgery.
• Specific diagnoses aren't always given in conservative care, leading to multiple treatment options with limited data.
• Patient history (H&P), goals, concerns, and beliefs are crucial in management.
• Imaging results don't always correlate with symptoms, and normal studies shouldn't rule out appropriate care.

Differential Diagnosis of Low Back and Lower Extremity Pain

• Spinal: Lumbar radiculopathy, facet joint arthritis, neurogenic claudication (due to lumbar spinal stenosis), fracture, and tumor are potential causes.
• Non-spinal: Intrarticular hip pain, piriformis syndrome, peripheral neuropathy, or vascular claudication can also be causes.

Red Flags (General)

• Night pain is a general red flag and should be noted

Neurologic Red Flags

• Bowel/bladder dysfunction (including overflow incontinence) often signifies a true surgical emergency.
• Progressive lower extremity weakness and sexual dysfunction are also significant findings.

Radiographic Red Flags

• Compression fractures, changes in pedicle appearance, new onset spinal malalignment, and changes in disc height with vertebral body end plate erosions should be examined for potential infections

Lumbar Disc Herniation

• Lumbar disc herniation most commonly affects young adults.
• Herniation vs. bulge vs. degeneration are different diagnoses and should be differentiated.

Discal Pathology

• MRI often helps with diagnosis
• Vertical herniation involves an extension through the endplate (superior/inferior protrusion).
• Most common in the lumbar spine and lower thoracic areas
• Commonly seen in adolescents and sometimes older adults following injuries.
• Treatments are usually conservative (such as bracing) to address discomfort and limitations.
• Location/direction of herniation affects symptoms (e.g., parasagittal).

Cervical Degenerative Disc Disease

• Neck pain and radicular symptoms (pain, weakness, or numbness) are common.

Myelopathy

• Clinical and imaging findings are crucial in assessment.

Axial Neck Pain

• Often disc-related in patients under age 55.

Cervical Radiculopathy

• Disc-related in under-55 patients.
• Over-55 patients are more likely to have spinal canal or foraminal stenosis-related.

Cervical Myelopathy

• Specific signs/symptoms are associated.

Non-operative Treatment for Spinal Pain Problems

• Education, physical therapy, activity modifications, bracing, and injections are possible, medications are also needed sometimes.

Medications

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used
• Other options like opioids (narcotics) and antidepressants may be considered for cases with chronic pain or neuropathic pain.

Diagnostic and Therapeutic Injections

• Different types of injections (e.g., trigger point, epidural, facet joint) are used
• These injections can be both diagnostic and therapeutic, and often used as adjunct treatments.

Efficacy of Epidural Steroid Injections (ESIs)

• Debated effectiveness as a treatment for lumbago (back pain), studies are often inconclusive.

Compression Fractures

• Common in high-risk populations (e.g., military personnel, distance runners, postmenopausal women)

Sacroiliac Joint Dysfunction

• Pain can be unilateral or bilateral, often localized to the posterior pelvis and thigh, or groin.
• Provocative activities and increased walking pace may worsen pain.
• Diagnosis and testing are needed to pinpoint the source of pain.

Diagnostic Testing

• X-rays, CT scans, and MRIs are possible tools for imaging.
• Fluoroscopically guided SI joint injections with local anesthetic are considered a standard diagnostic approach for sacroiliac (SI) joint problems.

Explore the conservative management strategies for spinal conditions, particularly low back pain. This quiz covers differential diagnoses, red flags, and the importance of patient history in treatment options. Test your knowledge on identifying conservative care protocols and evaluating the connections between imaging and symptoms.