L-4 Thoracolumbar Syndrome

• Thoracolumbar Clinical Syndromes is the topic

Objectives

• Recognize common thoracolumbar conditions
• Interpret radiographic studies for patients with back pain
• Arrive at a diagnosis for patients with back pain
• Formulate a treatment plan for future patients with back pain
• Identify common clinical scenarios related to back pain and how to address them

Imaging for Back Pain

• Imaging is not required for all patients with low back pain
• Neurodiagnostic imaging studies have high sensitivity but low specificity

Imaging Indications

• Young patients (under 18 years old)
• Patients older than 50 years old
• Trauma cases
• Patients who have a neurologic deficit

Low Back Pain Imaging Guidelines

• Vertebral Fracture:
• Osteoporosis combined with corticosteroid use and advanced age
• Trauma
• Cancer: unexplained weight loss, multiple risk factors for cancer
• Ankylosing Spondylitis:
• Younger patients present with morning stiffness improving with exercise
• Alternating buttock pain and night awakening

MRI Indications

• Neurologic Deficits: Central or peripheral nervous system compression or disease.
• Infection: Fever, recent infection, or IV drug abuse history.
• Cancer: History of cancer with new onset low back pain.
• Cauda Equina Syndrome: Urinary retention, motor deficits, fecal incontinence, or saddle anesthesia.

Plain Radiograph Views

• AP View shows transverse processes, psoas muscle, and scoliosis
• Lateral View shows disk space narrowing, compression fractures, facet joints, vertebral endplate changes, and kyphosis/lordosis
• Spot View provides information about L5-S1 intervertebral disk space and alignment
• Oblique View demonstrates facet joints and pars interarticularis, may reveal "Scotty dog" shape in the lumbar spine.

Thoracic Spine Radiograph View

• Bony Landmarks:
• Rib
• Pedicle
• Intervertebral disc
• Costotransverse joint
• Transverse process
• Vertebral body
• Costovertebral joint
• Spinous process

Lumbar Spine

• Anatomical Features:
• Pedicle
• Vertebral foramen
• Spinous process
• Transverse process
• Intervertebral disc
• Inferior vertebral notch of L2 vertebra
• Intervertebral disc space
• Superior vertebral notch of L3 vertebra
• Pedicle of L3 vertebra
• Intervertebral foramen
• Inferior articular process of L3 vertebra
• Superior articular process of L4 vertebra
• Spinous process of L4 vertebra
• Vertebral body

Spinal Curves

• Cervical lordosis
• Thoracic kyphosis
• Lumbar lordosis
• Sacral kyphosis
• C2-3 corresponds to the mandible
• C3 corresponds to the hyoid bone
• C4-5 corresponds to the thyroid cartilage
• C6 corresponds to the cricoid cartilage
• C7 corresponds to vertebra prominens
• T3 corresponds to the spine of scapula
• T8 corresponds to the level that inferior vena cava pierces respiratory diaphragm
• T10 corresponds to:
• Xiphisternal junction
• Level that esophagus pierces respiratory diaphragm
• T12 corresponds to:
• Level that aorta pierces respiratory diaphragm
• L1 corresponds to the end of spinal cord (conus medullaris)
• L3 corresponds to the subcostal plane
• L3-4 corresponds to the umbilicus
• L4 corresponds to bifurcation of abdominal aorta
• L4 corresponds to the iliac crests
• S2 corresponds to the end of dural sac

Posture

• Kypholordotic posture includes:
• Exaggerated lumbar curve, forward head, and rounded shoulders
• Lordosis posture includes:
• Increased lumbar curve, anterior pelvic tilt, and hyperextended knees
• Flat back posture includes:
• Decreased lumbar curve, posterior pelvic tilt, and hips flexed forward
• Military posture includes:
• Increased lumbar curve, anterior pelvic tilt, and extended thoracic spine
• Anterior postural deviation posture includes:
• Forward head, rounded shoulders, and flexed hips and knees
• Posterior postural deviation posture includes:
• Extended hips with knees slightly flexed
• Rotary posture includes:
• Rotated trunk with one shoulder or hip forward

Spinal Curvature

• Kyphotic curves refer to the outward curve of the thoracic spine at the level of the ribs
• Lordotic curves refer to the inward curve of the lumbar spine, just above the buttocks
• Scoliotic curving is a sideways curvature of the spine and is always abnormal
• A small degree of both kyphotic and lordotic curvature is normal
  • Too much kyphotic curving causes round shoulders or hunched shoulders (Scheuermann's disease)
• Too much lordotic curving is called swayback (lordosis)
  • Lordosis tends to make the buttocks appear more prominent

Exaggerated Thoracic Kyphosis

• Long-term poor posture can lead to exaggerated thoracic kyphosis
• Imbalances in muscle strength can contribute to abnormal spinal curvature
• Conditions like Scheuerman's disease, osteoporosis, and Paget disease can affect spinal structure
• Somatic dysfunction of flexed articulation

Impact on Respiratory Function

• Kyphotic Curvature of the spine moves ribs downward, diminishing or eliminating intercostal spaces
• Intercostal Muscle Loss prevents upward and outward movement of ribs on inhalation
• Compromised Respiration reduces the depth of respiratory excursion and efficacy of respiratory movements

Scheuermann's Disease

• Juvenile kyphosis
  • Developmental disorder causing increased kyphosis in the thoracic spine
  • Presents in adolescence with back pain and postural changes
  • Radiographs show anterior wedging of 3 adjacent vertebral bodies

Epidemiology and Clinical Features of Scheuermann's Disease

• Accounts for up to 20% of cases in specialty clinics for children and adolescents with back pain
• The estimated prevalence ranges from 4 to 8%
• More common in males with tall males at increased risk for severe disease
• Wedging may reflect compression fractures associated with osteoporosis or stress on the spine due to a short sternum
• May be associated with spondylolysis and, rarely, myelopathy
• Patients have a rigid kyphosis with a sharp angulation
• Curvature does not flatten with forward bending/extension/lying supine
• Compensatory increases in lumbar lordosis and hamstring tightening

Scheuermann's Disease Treatment

• Surgical Correction is considered if pain is persistent or kyphosis exceeds 60°
• Orthopedic Interventions may use bracing in severe cases
• Conservative Management uses strengthening and stretching exercises, osteopathic manipulation, and analgesics for pain control

Osteoporosis

• Bones become weak and brittle, increasing the risk of fractures
• Bone resorption outpaces bone formation, leading to decreased bone density
• Sarcopenia, or loss of muscle mass, can significantly affect a person's mobility and quality of life

Osteoporosis and the Downward Spiral

• Compromised Respiration causes hypoxia and reduced motion
• Increased Bone Loss due to restricted movements
• Progressive Kyphosis causes loss of thoracic motion

Axial Osteoporosis

• Vertebral compression fractures cause continuous (acute) or intermittent (chronic) back pain from the midthoracic to the midlumbar region, and occasionally to the lower lumbar region

Characteristics of Osteoporosis

• Etiology involves postmenopausal women, genetics, vitamin D synthesis deficiency, and idiopathic factors
• Risk factors involves family history, white female, increasing age, estrogen deficiency, vitamin D deficiency, low calcium intake, smoking, excessive alcohol use, and an inactive lifestyle
• Complications include vertebral compression fractures, fracture of proximal femur or humerus, ribs, and distal radius (Colles' fracture)

Diagnosis of Osteoporosis

• T-score calculates standard deviations from the average bone mineral density (BMD) of healthy young women
  • Osteoporosis is diagnosed when T-score < -2.5 SD
• Z-score calculates standard deviations from the average BMD of women of the same age as the patient

Osteopenia vs Osteoporosis

• Osteoporosis = T-score < -2.5 SD (2.5 SD or more below the average BMD mean value)
• Osteopenia = T-score between -1 and -2.5 SD

Clinical Risk Factors for Fracture

• Advancing age
• Female gender
• Low body weight (less than 58 kg [127 lbs])
• Previous fracture
• Parental history of hip fracture
• Glucocorticoid therapy
• Rheumatoid arthritis
• Secondary osteoporosis
• Hypogonadism or premature menopause/malabsorption/chronic liver disease or inflammatory bowel disease
• Current cigarette smoking
• Excessive alcohol consumption (3 or more units/day)

FRAX® (Fracture Risk Assessment Tool)

• Used to assess the risk of fracture
• Consider bisphosphonates, elemental calcium 1200 mg, and vitamin D 800 international units
• Smoking cessation and avoidance of heavy alcohol use
• Weight-bearing and muscle-strengthening physical activity are beneficial

Osteoporosis - OMT

• Use of osteopathic manipulative treatment for pain relief should involve mainly indirect techniques
• NEVER HVLA (high-velocity, low-amplitude thrust)

Excessive Lumbar Lordosis

• Pregnancy/obesity can lead to excessive lumbar lordosis due to changes in body weight distribution
• Extended somatic dysfunction in the lumbar spine or compensatory dysfunctions in pelvic/thoracic regions
• Spinal Diseases: Spondylolysis and Spondylolisthesis
• Muscle Weakness: Abdominal wall muscle weakness can contribute

Lordosis, Spondylolysis, Spondylolisthesis

• Spondylosis is age-related degeneration of the spine affecting discs and facet joints causing arthritis of the spine
• Spondylolysis is a defect or stress fracture in the pars interarticularis of the vertebra
• Spondylolisthesis is forward slippage of a vertebra over the one below, often due to spondylolysis

Anterolisthesis, Spondylolisthesis, Retrolisthesis

• Anterolisthesis is anterior displacement of a vertebral body relative to the one below.
• Spondylolisthesis is anterolisthesis secondary to spondylolysis used to denote anterolisthesis from any cause
• Retrolisthesis is posterior displacement of a vertebral body relative to the one below

Symptoms and Presentation of Spondylolisthesis

• Children and Adolescents are often asymptomatic or with mild symptoms
  • May present with changes in gait or posture, dull ache in buttock/posterior thigh, tight hamstrings (80% of cases), or difficulty touching toes
• Adults are more likely to experience pain, typically:
  • Low back pain, with/without radiculopathy
  • Pain aggravated by activity/prolonged standing and relieved with rest/limited activity.
  • Possible neurological symptoms in severe cases
  • Laxity of the pelvicotrochanteric group and hamstrings able to touch toes without bending knees or obliterating lumbar lordosis

Physical Examination Findings of Spondylolisthesis

• Palpation reveals anteriorly located spinous process or drop-off sign and increased intersegmental motion in the lumbosacral region
  • Paraspinal tissues are boggy/congested
• Range of Motion: Decreased forward flexion due to tight hamstrings
  • Increased flexibility in older patients with degenerative spondylolisthesis
• Only 2% of young patients show objective neurologic changes
• Postural Assessment reveals flared ilia, forward-thrusted abdomen, short waist, and flattened heart-shaped buttocks in severe cases

Types of Spondylolisthesis

• Type I (Dysplastic): Congenital deficiency of neural arch of L5 or upper sacrum and insufficiency of superior sacral facets
• Type IIA (Isthmic): Pars interarticularis defect due to lytic-fatigue fracture of pars
• Type III (Degenerative): Degenerative changes at apophyseal joints due to long-standing intersegmental instability
• Type IV (Traumatic): Due to fractures in other areas of the bony hook other than the pars
• Type V (Pathologic): Generalized or localized bone disease like neoplasm/Paget disease

Grades of Spondylolisthesis

• Grade I: 1 to 25% slip
• Grade II: 26 to 50% slip
• Grade III: 51 to 75% slip
• Grade IV: 76 to 100% slip
• Grade III and Grade IV slips and some milder grade slips may benefit from surgery if persistent and disabling symptoms are present

Scotty Dog

• Term used for visualization of the pars interarticularis
• Spondylolysis: "Scotty dog with collar"
• Spondylolisthesis: "Scotty dog decapitated"

Spondylolisthesis Examination & OMT

• Reduce lumbar lordosis, address somatic dysfunction, and promote maximal functional weight-bearing posture
• Starting with Pelvic and Sacral Balance
• Focus on balancing the pelvis horizontally, unilateral sacral shear, and leveling the sacral base
• Consider All Regions
  • Treat hamstrings, thoracic spine, thoracolumbar junction, diaphragm, and quadratus lumborum
• Address lumbars, use indirect techniques
  • Avoid HVLA in the lumbosacral area
• OMT: Soft tissue, counterstrain, myofascial release, and fascial unwinding techniques

Conservative Spondylolisthesis Management

• Back School provides 36 hours of instruction on back mechanics and optimal back care
  • Emphasize flexion-type exercises and include pelvic narrow/coil exercises
• Proper Lifting Techniques: Lift correctly and avoid improper lifting to reduce lumbar lordosis
• Posture Improvement: Advise on correct sleeping, sitting, and standing postures and wearing proper footwear
• Weight Management: Counsel on weight loss if necessary to reduce stress on the spine

Outcomes for Conservative Spondylolisthesis Management

• 85-90% Conservative Success Rate for degenerative spondylolisthesis in adults
• 76% Improved Outcomes when combining manipulation, exercise, and functional orthosis
• 50% Pediatric Success Rate for symptomatic children managed conservatively, severe cases require potential surgical intervention
• Ongoing monitoring and adjustments to the treatment plan are essential for optimal outcomes

Loss of Lumbar Lordosis

• Muscular Etiology: Paravertebral muscle spasm
• Disease Etiology: Ankylosing spondylitis
• Somatic Etiology: Flexed or neutral somatic dysfunction in the lumbar spine and compensatory dysfunctions in pelvic or lowerextremity regions

Seronegative Spondyloarthropathies

• Psoriatic Arthritis
• Ankylosing Spondylitis
  • Bamboo Spine, Flat Back
• Inflammatory Bowel Disease-associated Arthritis
  • Crohn's or Ulcerative Colitis
• Reactive Arthritis (Reiter's Syndrome)
  • Follows to enteric infection by Yersinia, Shigella, Salmonella, or Campylobacter

Ankylosing Spondylitis

• Seronegative spondyloarthropathy lacking typical markers (ANA, Anti-CCP)
• Inflammatory arthritis affecting the spine and sacroiliac joints.
• Affects 1 in 2000 persons, Men > Women (3:1 ratio), manifests in 20's to 30's
• Genetic association with HLA-B27 gene (90% of AS cases), family history increases risk

Early Symptoms of Ankylosing Spondylitis

• Gelling phenomenon (prominent stiffness and pain in the morning) AND back pain that forces the individual out of bed at night
• Sacroiliitis: gluteal pain that radiates down the posterior thigh is misdiagnosed as hip disease or sciatica
• Disease Progression:calcification of the anterior spinal ligament leads to fusion of the spine, "bamboo spine."

Management and Treatment of Ankylosing Spondylitis

• Medications such as NSAIDs, DMARDs and Biologics
• Prescribe Osteopathic Manipulation to helps maintain joint function if started early
• Promote Physical Therapy, emphasize exercises to maintain flexibility and posture
• In severe cases surgery and joint replacement may be performed

Psoas Syndrome

• Complex condition affecting the psoas muscle, which connects the lower back to the hips
• A chronic psoas spasm can create a persistent strain across the lumbosacral junction
• Impedes resolution of lumbosacral somatic dysfunction in spite of osteopathic manipulative therapy and exercises

Attachments of Psoas

• Psoas muscles attach to the vertebral bodies and anterior surface of the lumbar vertebrae's transverse processes and pass along the pelvis
• Joins the iliacus muscles, and insert on the lesser trochanter of each femur

Biomechanical Function of Psoas

• Primary function is hip flexion
• As a long restrictor muscle spanning multiple joints, it affects the hip joint, SI joint, & lumbar spine

Causes of Psoas Syndrome

• Prolonged Shortened Positions: sitting in soft chairs or bending over for extended periods/working at a desk.
• Overuse: Activities like doing sit-ups with fully extended lower extremities.
• Sudden Movements: Getting up quickly after prolonged sitting or bending can trigger the syndrome.
• Underlying Conditions: Disk herniations/organic issues like arthritis, diverticulitis, or prostatitis.

Signs and Symptoms of Psoas Syndrome

• Lower Back Pain: Central lower back pain accompanied by sciatic-type pain down the opposite leg
• Postural Changes: Patients may walk flexed forward/listing to one side, severe cases may present with hip flexion contracture
• Lower Extremity: Shortening and external rotation of the ipsilateral lower extremity, with possible Trendelenburg gait

Lumbar Dysfunction with Psoas Syndrome

• L1 or L2 vertebrae is flexed, rotated, and sidebent ipsilateral to hypertonic psoas

Pelvic Shift with Psoas Syndrome

• Pelvic side shift occurs contralateral to hypertonic psoas

Sacroiliac Joint with Psoas Syndrome

• Restrictions caused by psoas hypertonicity compressing SI joints and Backwards torsion around ipsilateral hypertonic axis

Compensatory Changes with Psoas Syndrome

• Contralateral piriformis trigger point and sciatic nerve pain above the knee
• Ipsilateral has externally rotated short left leg
• Long term dysfunction can lead to compensatory changes in the thoracolumbar junction/lumbar spine

Diagnosis of Psoas Syndrome

• Type II (flexed) L1 or L2 rotated and side bent to the left where Sacral torsion dysfunction (right torsion on a left oblique axis) with Pelvic side shift to the right
• Right piriformis trigger point and sciatic nerve pain above the knee along with Left externally rotated short left leg
• Prone and Supine Tests compare tension/end feel during Hip Extension & positive Thomas test on left Hip Flexion
• Palpatation indicates tenderness with in Psoas and Iliacus
• Rule Out Organic Causes: Like arthritis, diverticulitis, or prostatitis

Osteopathic Manipulative Treatment Approach for Psoas Syndrome

• Address Key Dysfunction via L1 or L2 somatic dysfunction
• Resolve Psoas Tension using techniques to relieve psoas hypertonicity
• Treat Associated Areas address lumbosacral, sacral, and pelvic dysfunctions
• Patient Education Provide home exercises and preventive strategies

Management of Psoas Syndrome

• OMT (Counterstrain, Myofascial Release, Still Technique, Muscle Energy)
• Home Exercises (prescribe specific stretches and exercises for the psoas muscle)
• Lifestyle Modifications (Advise on posture, ergonomics, plus activity modifications)
• Additional Therapies (Consider ice, medications, or treatment of underlying conditions if necessary)

Quadratus Lumborum Syndrome

• Myofascial pain syndrome caused by spasm and hypertonic quadratus lumborum muscle in the flank region, along the iliac crest, and around the front of the upper groin with referral into the sacroiliac joint
• Caused by poor posture and sitting in a slumped position

Anatomy and Function of the Quadratus Lumborum

• 12rh rib, transverse processes of L1-L4 vertebrae insertion and iliolumbar ligament connection
• Stabilizes/depresses -12th rib
• Ipsilateral sidebending Extends lumbar spine via bilateral contraction

Symptoms and Presentation of Quadratus Lumborum Syndrome

• Postural Changes resulting in extended and side-bent affected side
• Limited Range of Motion Contralateral side-bending and flexion becomes limited and painful
• Muscular Weakness indicates Opposite quadratus lumborum muscle becomes weak and pain
• Develop Trigger Points produce aching/sharp pain primarily worse standing

Physical Exam Findings for Quadratus Lumborum Syndrome

• Side-bent toward the contracted side
• Spinal Curve: Neutral group curve type 1 somatic dysfunction (side-bending toward and internal rotation away)
• Pelvic Alignment: Elevated pelvis on contracted quadratus lumborum side
• Leg Length: Apparent short leg on affected side because the muscle "pulls up" on the leg

Palpation and Range of Motion Evaluation for Quadratus Lumborum Syndrome

• Palpation will reveal hypertonic and tender quadratus lumborum muscles and transverse processes.
• There is Decreased flexion with pain to bending side

Special Tests for Quadratus Lumborum Syndrome

• Hip Drop Test will produce a restriction to Hip Motion
• There is Leg Length Shortening
• Quadratus Luborum Strength Tests show restriction

Treatment of Quadratus Lumborum Syndrome

• OMT techniques like Muscle Energy, Myofascial Release, & Counterstrain
• Follow up with Trigger Point Therapy and specific exercises

Viscerosomatics

• Viscerosomatic reflexes provide diagnostic clues on the somatic system (muscles, joints, blood, & lymph)
• Caused by a visceral disorder or disease which similar TART findings, that are in fact a reflex from the viscera
• Sympathetic nervous system and Parasympathetic Nervous System involvement