Classifications of spinal pain

Low back pain (LBP) is defined as pain and discomfort that are localized below the costal margin and above the inferior gluteal folds with or without leg pain. LBP is further defined according to the duration of an episode: acute, less than 6 weeks; subacute, between 6 and 12 weeks; chronic, 12 weeks or more (Table 1.1).

Table 1.1 Classification of Low Back Pain According to Duration of Episode

Recurrent low back pain is defined as a new episode of pain that occurs after a symptom-free period of 6 months and is not an exacerbation of chronic LBP. A recurrent acute episode is an episode in which the current symptoms have persisted 6 weeks or less and had improved prior to the current episode, separating it from previous episodes.

Nonspecific low back pain is defined as low back pain that is not attributed to recognizable, known, specific pathology (e.g., infection, tumor, osteoporosis, ankylosing spondylitis, fracture, inflammatory process, radicular syndrome, or cauda equina syndrome) (Box 1.1).

Chronic pain is defined as pain that:

The four diagnostic categories of LBP according to ICD-9 (International Classification of Diseases and Related Health Problems, 9th revision) [1] in the absence of symptoms that suggest serious underlying disease (e.g., cancer, cauda equina syndrome, significant or progressive neurologic deficit, or other systemic illness) are as follows:

Table 1.2 Diagnosis and Treatment of Acute Low Back Pain

Diagnostic triage of acute LBP consists of the following conditions (see Box 1.1):

Red flags in the diagnosis of LBP are signs that a serious spinal pathology may be the cause of the LBP; they are listed in Table 1.3:

Table 1.3 Red and Yellow Flags in Diagnosis of Low Back Pain

Signs or symptoms of neurologic involvement in a patient with LBP are complaint of numbness or weakness in the legs and sciatica with radiation past the knee. The following features apply to possible diagnosis of sciatica:

Because more than 95% of lumbar disc herniations occur at the L4-L5 or L5-S1 level, the neurologic examination should focus on the L5 and S1 nerve roots; however, upper lumbar nerve root involvement may be suggested when pain conforms to an L2, L3, or L4 dermatomal distribution and is accompanied by anatomically congruent motor weakness or reflex changes.

Psychosocial yellow flags are patient factors that increase the risk for development or perpetuation of chronic pain and long-term disability (including work loss associated with LBP); examples are listed in Table 1.3. Identification of yellow flags should lead to appropriate cognitive and behavioral management.

Considerations for diagnosis

Cauda equina syndrome is a condition requiring emergency evaluation and surgery. A patient with LBP should be referred immediately to the emergency room if any of the following emergency symptoms is present:

A patient should be examined within 24 hours if the patient requests a same-day appointment or any of the following urgent symptoms is present:

Is evaluation indicated? A patient should be offered an appointment within 2 to 7 days if any of the following symptoms or patient factors is present:

Performance of lumbar spine radiographs should be limited to presence of any of the following red flag indications:

Advanced imaging studies should be performed only for the patient with the following findings:

Epidemiology of low back pain

The lifetime prevalence of LBP is reported as more than 70% in industrialized countries (1-year prevalence, 15% to 45%; adult incidence, 5% per year). Peak prevalence occurs between ages 35 and 55.

Symptoms, pathology, and radiologic appearances in patients with LBP are poorly correlated. Pain is not attributable to pathology or neurologic encroachment in about 85% of people. About 4% of people seen with LBP in primary care have compression fractures, and about 1% have a neoplasm. Ankylosing spondylitis and spinal infections are even more rare. The prevalence of prolapsed intervertebral disc is about 1% to 3%.

Risk factors for LBP are poorly understood. The most frequently reported are as follows:

Outcomes

The aims of treatment for acute LBP are as follows:

Relevant outcomes for acute LBP are as follows:

Intervention-specific outcomes may also be relevant; examples are as follows:

Physical Examination

A physical examination for patients with symptoms of spinal pain would include palpation for spinal tenderness, neuromuscular testing, and the straight-leg raise (SLR) test. Table 1.5 summarizes the examination, techniques, and their clinical application in the patient with a complaint of low back pain.

Table 1.5 Physical Examination of the Spine

Neuromuscular testing should be performed to evaluate the following aspects:

▪ Motor: ankle and greater toe dorsiflexion strength

▪ Reflex: ankle and knee reflexes

▪ Sensory: pinprick sensation in the medial, dorsal, and lateral aspect of the foot

Significant or progressive neuromotor deficit requires surgical consultation.

The SLR test should be performed bilaterally to evaluate for nerve root impingement including, but not limited to, disc herniation. A positive SLR test result is defined as the presence of pain in the posterior leg that radiates below the knee when the patient is lying supine and the hip is flexed 60 degrees or less; it is suggestive of disc herniation. A negative SLR test result rules out surgically significant disc herniation in 95% of cases.

Related anatomy and physiology

The spinal muscles on the neck and back are described in Tables 1.6 through 1.9. The spinal nerves are described in Tables 1.10 through 1.15 and shown in Figures 1-1 and 1-2. The spinal blood supply is shown in Figures 1-3 and 1-4 and described in Table 1.16. The intervertebral foraminal ligaments of the lumbar spine are shown in Figure 1-5.

Table 1.6 Anterior Neck Muscles: Origins, Insertions, Actions, and Related Innervations

Table 1.7 Posterior Neck Muscles (Suboccipital Triangle): Origins, Insertions, Actions, and Related Innervations

Table 1.8 Superficial (Extrinsic) Posterior Neck and Back Neck Muscles: Origins, Insertions, Actions, and Related Innervations

Table 1.9 Deep (Intrinsic) Posterior Neck and Back Neck Muscles: Origins, Insertions, Actions, and Related Innervations

Table 1.10 Anterior and Posterior Branches of the Spinal Nerves

Table 1.11 Cervical Plexus (C1-C4 Ventral Rami) behind Internal Jugular Vein and Sternocleidomastoid (SCM) Muscles

Table 1.12 Brachial Plexus

Table 1.13 Lumbar Plexus

Table 1.14 Sacral Plexus and Coccygeal Nerves

Table 1.15 Spinal Nerve Branches and the Territories They Supply

* Strictly speaking, the gray ramus communicans is not a spinal nerve branch but a branch passing from the sympathetic trunk to the spinal nerve.

Figure 1–1 Anterior view of the nerves of the trunk wall.

Figure 1–2 Branches of the spinal nerves. Formed by the union of the dorsal (sensory) and ventral (motor) roots, the approximately 1 cm–long spinal nerve courses through the intervertebral foramen and divides into five branches after exiting the vertebral canal (see Table 1.15).

Figure 1–3 Composite schema of blood supply to the spinal cord and nerve roots showing two regions of the cord. Note the distribution between medullary arteries and true radicular arteries and that the medullary arteries usually run a course that is independent of the roots. 1, Dorsolateral longitudinal artery; 2, proximal radicular artery (of dorsal root); 3, dorsal medullary artery; 4, dorsal root of the thoracic spinal nerve; 5, distal radicular artery (of dorsal root); 6, sinuvertebral nerve; 7, dorsal ramus of spinal nerve; 8, segmental artery; 9, dorsal central artery; 10, dorsal root ganglion; 11, anterior laminar artery; 12, ventral ramus of spinal nerve; 13, rami communicantes; 14, ventral root of spinal nerve; 15, proximal radicular artery of ventral root; 16, periradicular theca of dura; 17, dorsal meningeal branch of vertebromedullary artery; 18, dura; 19, ventral meningeal plexus; 20, great ventral medullar artery (great “radicular” artery of Adamkiewicz); 21, anterior (ventral) spinal artery; 22, vasa corona of spinal cord; 23, spinal nerve; 24, ventral medullary artery of thoracic cord.

Figure 1–4 Schema showing the venous relations of a lumbar vertebra. The divisions of the network are the internal vertebral plexus, which surrounds the dura and is drained by veins in the intervertebral foramina; the basivertebral veins on the back of the vertebral bodies, which drain a network in the marrow spaces of the vertebrae; and the external vertebral plexus, which lies on the anterior and lateral sides of the vertebral bodies and on the vertebral arches. 1, Dorsal external vertebral plexus; 2, dorsal epidural plexus; 3, ascending lumbar veins; 4, basivertebral vein; 5, anterior ventral external vertebral plexus; 6, lumbar segmental vein; 7, muscular vein from posterior abdominal wall; 8, circumferential channels (sinuses) of epidural plexus; 9, ventral epidural plexus; 10, internal ventral and dorsal venous plexus; 11, lateral ventral external vertebral plexus.

Table 1.16 Spinal Arteris^*

Figure 1–5 Intervertebral foraminal ligaments of the lumbar spine: A, corporo-transverse superior and corporo-transverse inferior; B, superior transforaminal ligament ; C, mid- transforaminal ligament; D, inferior transforaminal ligament; E, posterior transforaminal ligament. Enlarged image shows all ligaments in context.

(Modified from Park HK, Rudrappa S, Dujovny M, Diaz FG: Intervertebral foraminal ligaments of the lumbar spine: Anatomy and biomechanics. Childs Nerv Syst 2001;17:275-282.)

Imaging studies

The indications for and advantages of magnetic resonance imaging (MRI) and computed tomography (CT) in the evaluation of low back pain are summarized in Table 1.17.

Table 1.17 Magnetic Resonance Imaging (MRI) and Computed Tomography (CT): Indications and Advantages in the Evaluation of Low Back Pain

	MRI	CT
Indications
Major or progressive neurologic deficit (e.g., foot drop or functionally limiting weakness such as hip flexion or knee extension)	Yes	Yes
Cauda equina syndrome (loss of bowel or bladder control or saddle anesthesia)	Yes	Yes
Progressively severe pain and debility despite conservative therapy	Yes	Yes
Severe or incapacitating back or leg pain (e.g., requiring hospitalization, precluding walking, or significantly limiting the activities of daily living)	Yes	Yes
Clinical or radiologic suspicion of neoplasm (e.g., lytic or sclerotic lesion on plain radiographs, history of cancer, unexplained weight loss, or systemic symptoms)	Yes	Yes
Clinical or radiologic suspicion of infection (e.g., end plate destruction on plain radiographs, history of drug or alcohol abuse, or systemic symptoms)	Yes	No
Severe low back pain or radicular pain that is unresponsive to conservative therapy and with indications for surgical intervention	Yes	No
Bone tumors (to detect or characterize)	No	Yes
Advantages	Better visualization of soft tissue pathology Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Lateral Interbody Fusion Using the XLIF System Percutaneous Lumbar Restabilization via a Posterolateral Approach Sacroiliac Joint Block and Neuroablation Anterior Endoscopic Cervical Microdecompression of Disc and Foramen Outcome Measurements for Minimally Invasive Percutaneous Spine Techniques Spinal Cord Stimulation Stay updated, free articles. Join our Telegram channel Join Tags: Minimally Invasive Percutaneous Spinal Techniques Aug 5, 2016 | Posted by admin in NEUROSURGERY | Comments Off on Diagnosis and Treatment of Spinal Pain Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access