L-5 Osteopathic Considerations for Back Pain

• Back pain involves osteopathic considerations in the thoracic and lumbar regions.
• Nathan Widboom, DO, is the author of the presentation.
• The spine includes 7 cervical, 12 thoracic, and 5 lumbar vertebrae, plus the sacrum and coccyx.

Introduction and Epidemiology

• Back pain is the second most common symptom-related reason for clinician visits.
• Back pain is experienced by 84% of adults at some point in their lives.
• Back pain accounts for 2.5% of all clinician visits.
• Back pain costs $100 billion annually.

Risk Factors

• Risk factors for back pain include:
  • Smoking, obesity, and older age
  • Female gender and physically strenuous work
  • Sedentary and psychologically strenuous work
  • Low educational attainment and workers' compensation insurance
  • Job dissatisfaction Psychological factors such as somatization disorder, anxiety, and depression.
• Psychosocial variables are stronger predictors of disability than structural spine changes.

Prognosis

• 90% of primary care patients do not seek care after 3 months for back pain.
• Most patients still have pain after one year but do not seek care
• A high expectation for recovery correlates with greater functional improvement, regardless of MRI results.
• Predictors of poor outcomes include:
  • Maladaptive pain coping behaviors
  • Functional impairment
  • Poor general health status
  • Presence of psychiatric comorbidities.

Spinal Anatomy

• Spinal anatomy includes intervertebral discs, the nucleus pulposus, annulus fibrosus, spinal cord.
• Spinal anatomy also includes the transverse and spinous processes, superior articular facet.

Facets and Joints

• Relevant anatomical features include:
  • Superior articular facets, facet for the tubercle of the rib.
  • Transverse and spinous processes, and the angle of the rib.
  • Superior and inferior costal facets, the head and neck of the rib.
• Costovertebral and Costotransverse Joints anatomy include:
• Vertebral body, the intervertebral disc, and the tubercle of the rib.

Ligaments

• Key ligaments:
  • Anterior longitudinal ligament
  • Posterior longitudinal ligament
  • Ligamentum flavum
  • Interspinous and supraspinous ligaments
• Other anatomical features include:
  • Lumbar vertebral body, the intervertebral disc, and the spinous process.
  • Inferior and superior articular processes.
  • The capsule of the zygapophyseal joint, transverse process and the intervertebral foramen.

Terminology

• Spondylosis is arthritis of the spine seen radiographically as disc space narrowing and arthritic changes.
• Spondylolisthesis is the anterior displacement of a vertebra, graded I-IV based on the degree of slippage.
  • Grades I and II are treated medically, Grades III and IV, and some milder cases, may need surgery if symptoms persist
• Spondylolysis is a fracture in the pars interarticularis, often at L5.
• Spinal stenosis is a narrowing of the spinal canal due to bone or soft tissue changes.
• Radiculopathy is impairment of a nerve root causing radiating pain, numbness, tingling, or weakness.
• Sciatica involves pain, numbness, and tingling along the sciatic nerve distribution.
• Cauda equina syndrome involves loss of bowel/bladder control and numbness in the groin, often due to spinal canal pressure.
• Kyphotic curves refer to the outward curve of the thoracic spine and Lordotic curves refer to the inward curve in the lumbar spine just above the buttocks.
• Scoliotic curving is a sideways curvature of the spine and is always abnormal.
• Too much kyphotic curving leads to rounded or hunched shoulders while too much lordotic curvature is called swayback.
• Piriformis syndrome is thought to compress/irritate the sciatic nerve, but lacks definitive diagnostic evidence.

Differential Diagnosis of Low Back Pain

• Mechanical low back pain includes lumbar strain, degenerative disc and facet joint disease, spondylolisthesis, and herniated discs.
• Non-mechanical spine disease includes neoplasms, infections (osteomyelitis, septic discitis), and inflammatory arthritis.
• Visceral diseases relate to pelvic organs, renal diseases, aortic aneurysm, and gastrointestinal issues.

Chronic Pain Treatment

• Osteopathic Manipulative Medicine (OMM) considers body unity, homeostatic, and structure-function issues.
• The integration of osteopathic principles and practice into treatments
• Algorithms include patient education and counseling.

Simplified Thought Process

• Three main categories for back pain Dysfunction, Derangement, and Degeneration
• Dysfunction is a lab application.
• Derangement disc herniation. Degeneration arthritis.
• Arthritis is a result of osteoarthritis, psoriatic, infectious, gouty/pseudogouty, ankylosing spondylitis

Lumbar Nerve Root Compromise

• Testing includes L4, L5, S1 nerve roots
• Assessing testing for pain, numbness, motor weakness, screening examination, and reflexes

Thoracic Region Differential Diagnosis

• Rule out fractures, malignancy/metastases, and infections such as multiple myeloma.
• Osteoporotic or traumatic compression fractures are important considerations
• Rule out visceral causes, such as:
  • Aortic dissection
  • MI
  • Pneumonia
  • Pneumothorax
  • Pericarditis
  • Hepatobiliary diseases
  • Nephrolithiasis/renal diseases

Spinal Disease

• Spinal diseases include disc disease and herniated discs, with only 1% being thoracic.
• Spondylosis, Spondylysis, Spondylolisthesis.
• Stenosis.
• Facet arthritis and Costovertebral joint inflammation can be factors.
• Somatic dysfunction of the vertebrae.

DISH

• DISH stands for Diffuse Idiopathic Skeletal Hyperostosis

• Hyperostosis of the thoracic spine may occur.

• Neural foramen has the ability to cause encroachment by Disc degeneration, Bone spurs(osteophytes), flattening of the disc

• Vertical Disc Herniation called, Schmorl's nodes

• DDX Thorax contains painful Shingles

DDX Thorax continued...

• Rib mediated:
  • Intercostal neuritis
  • Costovertebral joint pain and dysfunction
  • Somatic dysfunction of ribs (named by phase of respiration of position)

Lumbar Region Differential Diagnosis

• Rule out cauda equina and malignancy
• Rule out Disease of the spine and facets as in the thoracic region
• Possible muscular implications: Quadratus lumborum, psoas, paraspinals
• Possible Ligamentous implications: Iliolumbar ligament, Interspinous, A/P longitudinal
• Possible Neural implications: Sciatic, Cluneal nerve

Other Lumbar DDX considerations

• Quadratus Lumborum
• QL/Psoas Anterior View
• Iliolumbar ligament
• Cluneal Nerves

Further DDX Lumbar considerations

• Clinically: -Facetogenic pain causes Extension and rotation movements to be painful -Lumbosacral pain appears Upon standing or sitting

Diagnosis: Somatic Dysfunction

• Somatic Dysfunction is Impaired or altered function of related components of the somatic system
• Impairments typically effects skeletal, arthrodial, and myofascial structures, as well as their related vascular, lymphatic, and neural elements

"Dirty Half-Dozen" in "failed LBP"

• Nonneutral dysfunction within the lumbar spine, primarily flexed, rotated, and side bent (FRS) dysfunctions
• Dysfunction at the symphysis pubis
• Restriction of anterior nutational movement of the sacral base -either a posterior torsion or a posteriorly nutated (extended) sacrum possible
• Innominate (hip) shear dysfunction
• Short-leg, pelvic-tilt syndrome
• Muscle imbalance of the trunk and lower extremities

OMT

• Imaging may be prudent prior to OMT
• Use whichever technique is comfortable for you and your patient: Indirect or acute pain can occur
• Address compensatory dysfunction related to the T and L spine -including Ribs, thoracics, lumbars, sacrum, pelvis, lower extremities and related muscular and ligamentous elements
• "*AT LEAST"

LBP Treatments

• Lumbar treatments for muscle energy, Soft tissue, Counterstrain, FPR and/or MFR

• Sacrum treatments for muscle energy

• Pelvis treatments including muscle energy and HVLA (High-velocity low-amplitude thrust )

• Low extremity treatments for Hamstring muscles involving muscle energy or for Psoas and piriformis with Muscle energy, Counterstrain or Direct pressure applied

• Diaphragms releases for Thoracoabdominal doming and pelvis diaphragm

• Imaging evaluation for acute low back pain includes multiple signs and sympotms

• Signs and sympotms includes the presence of caua equina Imaging takeaways are used when radiculopathy is attributable to single nerve root, then order MRI when NO improvement in sympotms after 4-6 weeks of treatment

• Do not forget to order an immediate MRI when the risk of metastatic are present

Interventional Approach

• Prolotherapy involves the Injection of an irritant to stimulate a healing response: eg. Dextrose and other irritants or platelet rich plasma

• Muscle Spasm and Trigger Points are treated with Spray and Stretch techniques which can involve Injection (Dry needle or anesthetic)

• Epidural Injection types

• Caudal

• transforaminal

• translaminar: Flouroscopic Guidance with contrast while on a Non-particulate steroid

• Other approaches are Facet Blocks and Nerve Blocks for Intercostal Neuritis or as a Cluneal nerve

• Additional treatment can occur with Physical Therapy Evaluation. Additional treatments for low-back pain -Exercise -Core strenghthening or the McKinzie protocol. -Using topicals to decrease pain -Bracing to encourage postural strenghthening. -Accupuncture -Transcutaneous Electrical. Nerve Stimulation can occur with, (TENS,) -Spinal cord stimulation is a treatment as well as peripheral nerve stimulation

McKenzie Protocol

• McKenzie Protocol is a Reducible derangement -Shown to have one direction of repeated movement which decreases or centralizes referred symptoms which is an ideal or preferred direction. -shows also an opposite repeated movement characterized by production. -increase movement or a distillation of the sympotms.
• The treatment includes examination of the patients symptomatic and mechanical responses to repeated movements or sustained positions to assist in clinical treatment to induce directional preference.