Transcript Low Back Pain

Low Back Pain
What’s that?
The Problem
– 93 million work days lost annually for LBP.
– Cost of Tx for LBP is greater than Heart
Disease or Traffic Accidents.
– 2nd most common reason for seeking medical
care.
– 91% seeking Chiropractic care…did so for low
back pain
Facet Syndrome – Who?
• Chiropractic use by Seniors:
• “Those over 65 constitutes between 12 – 17 % of
the average Chiropractic practice.”
» Coulter et al. Chiropractic patients in a
comprehensive home based geriatric assessment,
follow up and health promotion program. Top
Clinical Chiropractor 1996; 3(2): 46-55.
Facet Syndrome – Who?
• Chiropractic Care and management of the
Geriatric patient…
– U.S. Department of Commerce:
• 1994 – 33 million over 65 ( 1 in 8 )
• 2000 – 13 % of the population over 65
• By 2030 – 20% of the population over 65, and
care for older patients will represent half of all
healthcare dollars
• 2050 (This means you!!!) – 80 million over the
age of 65 (1 in 5)
Facet Syndrome - Process
– Degenerative Disc Disease and Disc
Herniation…Physiological changes in the
intervertebral disc, beginning in the second decade,
progress throughout life with degenerative changes
resulting.
– As the nucleus pulposis and annulus fibrosis
degenerate, a bulging, herniation of the nucleus, or
even nuclear extrusion may occur…Thus, the
beginnings of LBP!!!
Facets - Normal
– Superimposed loads on the lumbar spine are
borne by the body-disc-body anteriorly and by
the two articular facets posteriorly…ligaments
provide stability for the posterior elements and
the intervertebral disc.
Facets - Normal
• The apophyseal joints are not loaded
heavily by compression (borne by the disc)
or flexion-extension…but can be heavily
loaded by A to P / P to A shear loads.
• The lumbar apophyseal joints function to allow limited movement
between vertebrae and to protect the discs from shear forces,
excessive flexion, and axial rotation. Not designed to resist
compression…that’s the job of the disc.
Facets - Normal
– Morris states that 70 % of the superimposed
body weight is carried on the vertebral bodies
and 30 % on the articular facets.
Morris JM, Lucas DB, Bresler B: Role of trunk in
stability of the spine. J Bone Joint Surgery 43A:
327, 1961
Facet Loading
•
Panjabi presents the following algorithm of the stages of injury to the F.S.U.:
• 1. Asymmetric disc injury at one F.S.U. level
• 2. Disturbed kinematics of F.S.U.’s above and below
• 3. Asymmetric movements at facet joints
• 4. Unequal sharing of facet loads
• 5. High load on one facet joint resulting in intraarticular cartilage
degeneration, joint space narrowing, and facet atrophy.
Facet Syndrome
– It is obvious that weight distribution on the facets
change with degenerative disc disease, in which
narrowing of the disc places disproportionately more
weight on the articular facets…as high as 47% to
70%
Facets
– With Disc thinning…an individual has an
increased articular weight bearing. This
contact between the facet tip and lamina is
labeled in Chiropractic as a
Facet - lamina syndrome.
Facet Lamina Syndrome
– Thus causing an abnormally high
impingement of the facet tips on the adjacent
lamina or pedicle, and the apophyseal joints
show gross osteoarthritic changes.
• It is possible that the joint capsule is nipped by
such high stress placed on the tips of the articular
facets…meniscoids!!!
Facets - Normal
– The mean articular facet area increases
suddenly at L4 & L5 as compared to the
upper lumbar levels, indicating that there is
more compressive force at the articular facets
in the lower than in the upper lumbar spine.
– T5 – L4…increase vertebral body size
Normal - R.O.M.
– 75% to 80% of all flexion / extension occur at
L5 / S1 region.
– 20% occurs at L4 / L5
– 5% occurs at the remaining upper levels…L3
and above.
L5 / S1
• Remember, the joint between L5 & S1 is the
single most common site for problems in the
vertebral column…Because of the following:
• The joint bears more weight than any other vertebral joint.
• Center of gravity passes directly through these two
segments.
• Transition site between mobile segment and relatively stable
pelvic girdle.
• Increased angle between L5 & Sacrum.
Facets
– The increased transfer of weight through the pedicles
at L5, which is an area of forward and downward
inclination of forces as L5 sits on the sacrum at an
inclined plane, has been offered as an explanation for
the stress leading to fracture of the Pars
interarticularis and resultant spondylolisthesis.
• Normal sacral angle & inclination…41° & 46 ° respectively.
Analysis…Facet Syndrome?
• Check facet imbrication & Stenosis…X-ray assessment.
• Check Disc angle…15° or More?
• Check X, Y & Z; Psoas; piriformis; Q.L.; anterior-ilio femoral
ligament; etc.
• Check A.P.I.
• Female 5 to 10 degrees…normal
• Male
0 to 5 degrees…normal
Radiographic assessment
Facet imbircation
(Radiographic Assessment)
• Check for unequal weight distribution via
X-rays:
•
•
•
•
Hadley’s “S” curve
Macnab lines
Lumbsacral angle
Van Akkerveeken lines
Facet imbircation
(Radiographic Assessment)
• Hadley’s “S” curve :
– Views: Oblique & A - P Lumbar spine
– A curvilinear line is constructed along the inferior margin of
the TVP and down along the inferior articular process to
the apophyseal joint space. The line is then continued
across the articulation to connect with the outer edge of the
opposing superior articular process.
– The resultant configuration of this line will be that
simulating the letter “S”. The key region of the “S” to
observe is normally a smooth transition across the joint
space.
– Significance: An abrupt interruption in the smooth contour
of this line signifies facet imbrication.
– Yochum and Rowe…pg. 192
Facet imbircation
(Radiographic Assessment)
• Macnab’s line:
– View: Lateral lumbar
– A line is drawn through and parallel to the inferior end
plate at the level to be evaluated. The relationship of the
adjacent tip of the superior articular process of the
vertebra below is then assessed.
» Significance: If the line intersects the superior
articulating process, facet imbrication may be
present…thus effecting the size of the
IVF…Stenosis!!!
» Combine Lumbosacral Disc Angle.
Facet imbircation
(Radiographic Assessment)
• Lumbosacral Disc Angle: (Combined with Macnab’s line for possible
vertical stenosis of L5/S1 IVF)
• View: Lateral lumbar
– A line is drawn parallel and through the inferior end plate of the
5th lumbar (Macnab’s line) and superior endplate of the 1st
sacral segment. The angle formed by these lines is then
measured.
» An increase in the lumbosacral disc angle more than 15°
has been linked with the presence of low back pain due to
facet imbrication.
» The greater the disc angle…the more severe the facet
syndrome…Cox pg. 447
» Y & R…pg. 189
Facet imbircation
(Radiographic Assessment)
• Van Akkerveeken’s measurement:
– View: Lateral lumbar spine
– Two lines are drawn through and parallel to opposing
segmental endplates until they intersect posteriorly. The
distance from the posterior body margins to the point of
intersection in then measured. Alternatively the displacement
can be assessed by measuring the offset in the opposing body
corners.
– Significance: A difference of 1.5 mm to 3.0 mm in
measurement shows a greater chance of nuclear, annular, and
posterior ligament damage at the displaced
segment….Instability.
– Measure the disc angle.
– Yochum & Rowe…pg. 192
Overview - Review
– 70% / 30%...normal weight bearing. Disc degeneration…Increase facet weight
bearing to 47% to 70%
– Facet – lamina syndrome…with disc thinning
– Normal facets…increase in size @ L4 / L5 region
– Normal Vertebral bodies increase in size from T5 to L4…L5 V.B. decreases. L5
increased angle…Normal sacral angle & inclination…41° & 46 ° respectively.
– Check X,Y, & Z; A.P.I.; Facet imbrication; stenosis; etc…
– Radiographic Assessments…Hadley’s “S” curve; Mcnab’s line; Lumbosacral
angle; Van akkerveeken’s line.
Normal Anatomy
– Canal at L5 – S1 is the smallest, yet the DRG there is the largest
in the lumbar spine.
– R.O.M. – 75% of Flexion / Extension…occurs at L5 – S1
– Center of gravity passes through L5 – S1.
– Transition point between the stable pelvic girdle and the mobile
lumbar vertebrae.
– Facets at L5 – S1 are usually at a 45 degree angle.
Diff / DX
– Sclerotome…one of the paired masses of
mesenchymal tissue, separated from the
ventromedial part of a somite, which develop
into vertebrae and ribs.
– Radiculopathy…disease of the nerve roots.
Diff / DX
• Sclerotogenous pain
•
•
•
•
Pain above the knee.
Diffuse LBP
No motor, No reflex, No dermatomal involement
Multiple causes
Facet Pain / Patterns
– T12 – L3: Facet Pain distribution – No leg or coccygeal pain.
Radiating pain to thoracic and cervical spines
– L3 – L4: F.P.D. – Upward to thoracic spine, diffuse flank and
groin pain & Coccyx
– L4 – L5: F.P.D. – Posterior hip and thigh & Coccyx.
– L5 – S1: F. P. D. – Coccyx; Hip; Posterior thigh; Groin; Flank.
– Lora J, Long D: So – called facet denervation in the management of
intractable back pain. Spine 1 (2): 121 – 126, 1976
Diff / DX
• Radiculopathy
• Contained
• Non – Contained
• Motor, Reflex, and Dermatomal involvement.
Sciatica
•
5 common causes:
1.
2.
3.
4.
5.
Herniated disc
Annular tears…chemical leakage
Myogenic
Spinal stenosis
Facet joint arthropathy
Herniated Disc
• Herniated nucleus pulposus:
•
•
•
•
History of specific trauma
Leg pain greater than back pain
Neurologic deficit present
Pain increases with sitting and leaning forward,
coughing, sneezing, and straining
• Radiologic evidence of nerve root compression
Facet Syndrome
• Panjabi presents the following algorithm of
the stages of injury to the F.S.U.
•
•
•
•
•
1. Asymmetric disc injury at one F.S.U. level
2. Disturbed kinematics of F.S.U.’s above and below
3. Asymmetric movements at facet joints
4. Unequal sharing of facet loads
5. High load on one facet joint resulting in intraarticular cartilage
degeneration, joint space narrowing, and facet atrophy.
Facet Syndrome
• “Facet fixations may set off a chain of events
leading to asymmetrical loading on the
epiphyseal plates and to muscle and
ligamentous imbalance, ultimately resulting
in curve progression”.
•
– Panjabi & White: Clinical Biomechanics of the spine.
Facet Pain
• Stretching of the joint capsule
may be a source of pain due to
the presence of a nociceptive
type IV receptor system.
• Joint receptors (Type I, II, & III mechanoreceptors)
provide information regarding such activities as the
direction, velocity, and initiation of joint movements—
achieved by responding to tension applied to the
connective tissue surrounding them.
• Type IV joint mechanoreceptor is unmyelinated, free
nerve endings and responds to potentially injurious
mechanical or inflammatory processes.
Facet Pain
– Wyke points out that the apophyseal capsule
contains unmyelinated nerve fibers. They are
sensitive to both chemical and mechanical
irritation, and high tensions develop in the
facets following disc degeneration and the
carrying of more weight.
Facet Pain
–
–
–
–
Wyke states that the cause of low back pain is
irritation of nociceptors.
The term Nociceptive means “sensitive to tissue
abnormality.”
Two abnormalities causing pain are mechanical and
chemical.
There are three morphological types of nociceptors
1. Unmyelinated fibers in interstitial tissues
2. Free naked nerve endings
3. Unmyelinated paravascular nociceptive system in the
adventitial layers of blood vessels.
Facet Pain
– Histological studies of sectioned “Z” joints
indicates the presence of an extensive
vascular supply. Since Vascular structures
may be related to pain, this may help explain
spinal pain of “Z” origin.
Facet Pain
– This sensory nerve supply is sufficiently developed to
support the hypothesis that irritation of the capsule of
the lumbar articular facets could well produce pain
stimuli.
– Which could return to the CNS through the posterior
primary division and produce referred pain through
the dermatomes of the involved nerves.
Facet Pain
• The capsule of the articular facets are richly
innervated with sensory fibers, according to Von
Luschka. The posterior primary division of the
spinal nerve (dorsal ramus) and the recurrent
nerve of the anterior primary division innervate
the capsule. Which correspond exactly with the
pathways of Sciatic radiation…namely the 4th
and 5th nerves.
Facet Pain / Patterns
• Lora and Long stimulated the facets…in
and around the facets.
– Typical radicular radiation is not generated by stimulation of the nerves
in and around the facet, but widespread referral of sensation even into
the leg is possible:
– This referral of sensation is difficult for the patient to localize, and has
not gone below the knee in any patient.
Facet Pain / Patterns
• Referred pain shares the same distribution as
the innervation of the affected Zygapophyseal
articulations.
• Pain arising from the L4 – L5 and L5 – S1
articulations will be felt in the posterior thigh, and
occasionally in the medial and lateral calf, and
back pain is usually greater than leg pain.
– The pain, occasionally, but rarely, extends beyond the
calf and into the foot.
Facet Pain / Patterns
• Schofferman and Zucherman feel that leg pain may
prove more useful diagnostically.
– The distribution and quality of the pain are used to separate
referred pain from radicular pain. Pain in the absence of
neurological deficit is referred pain, while pain in the presence of
neurological change is radicular.
– Schofferman J, Zucherman J: History and physical examination.
Spine: State of the Art reviews 1 (1): 14, 1986.
Facet Treatment
• The major benefits of flexion manipulation:
• Improvement of transport of metabolites into the
intervertebral discs, reduction of stress on the
apophyseal joints and on the posterior half of the
annulus fibrosus, and giving the spine a high
compressive strength.
Manipulation
• Benefits of Manipulation
• Increase Spinal range of motion
• Relieve nociceptor irritation
• Equalize the weight distribution…Thus, relieving
the compressive forces against the nerve root in
the vertebral canal & the I.V.F.
Facet Treatment
• Test the pt.’s tolerance prior to any manipulative
maneuver. A side lying maneuver to treat facet
subluxation syndrome when the patient is in too
much pain to lie prone.
• Place the Iliac crest in the middle of the abdominal piece.
• Start the table at ½ speed to check pt.’s tolerance…do not
continue if pt. experiences an increase in pain.
• Treat pt. in side lying position…Lateral flex the table (knees
bent), and pump the vertebra above the lesion.
Facet Syndrome
• Ghormley stated: “There is ample
evidence to regard facets as a cause of
sciatic pain. He used the term facet
syndrome to describe the sudden onset of
low back pain brought on by some activity
usually involving a twisting or rotatory
strain of the lumbosacral region”
• Ghormley RK: JAMA 101: 1773-1777, 1933.