• affect 50% of population
• usually between ages 30-60
• 90% occur at C5 and C6 level
• 2 types of lesions, with similar symptoms: 
  • Soft disc protrusion or nuclear herniation
  • spondylosis (hard disc lesion) more common

• mass of nucleus pulposus begins to bulge outward, usually posterolaterally
• severe protrusion may compress nerve root, causing arm symptoms and radicular pain
• less severe herniation may cause only referred or axial spine pain (unilateral)
• most common in younger pts

• results from chronic disc degeneration with subsequent settling or narrowing of the disc space and alterations in the surrounding structures includ. facet joints
• may lead to spur (osteophyte) formation along joint of Luscka, and mild subluxation of facet joints
• occurs mainly in older age groups (after 40)

• occurs when large osteophytes form along with degenerative narrowing of the bony canal and cause pressure on the spinal cord, producing mixed symptoms of UE nerve root pain and LE weakness.
• typical disc syndrome in UE, and gait difficulties, weakness, and spasticity in LE 
• most common cause of spastic paraparesis in adults

• Neck, interscapular and/or arm pain that is aggravated by neck motion is typical
• Initial: neck and referred pain (does not follow dermatome), often to interscapular area (unilateral)
• stiffness/pain in the neck that worsens with activity, in the morning and with extension or looking over the shoulder, coughing, sneezing or straining
• Rarely, pain in anterior chest (cervical angina) may be presenting symptom
• With nerve root irritation: pain, numbness or tingling may radiate into shoulder, arm and radial aspect of forearm. HA or jaw pain with high disc lesions

Adults: dorsal spine in the anulus fibrosus; probably 2° to degenerative process

Children: cervical spine in the nucleus pulposus

"calcific discitis", may cause other symptoms (mild torticollis, elevation of temp, sed rate, and WBC)

Tmt: soft collar, moist heat, NSAIDs, adn analgesics

• aka "wryneck"
• contraction of the muscles of the neck, causing head to tilt to one side
• usually a symptom of underlying disorder (more than 50 causes)
• may be acquired (trauma or dz)
• 80% is congenital 

• affects the nerve root exiting one level below, because that is the nerve that passes over the disc
• i.e. herniation between the L4 and L5 affects L5 nerve root

• GI/GU symptoms (incontinence can be d/t compression of cauda equina) 
• General systemic complaints: fever, wt loss, night sweats, other joint sxs (sig morning stiffness)
• smoking Hx, substance abuse
• Hx of CA
• pain at rest (suggests infection or CA)
• loss of strength and/or balance

• Pain on bending toward affected side: generally disc dz
• pain on bending away from affected side: muscle strain
• weak heel walking: L5 root problems
• weak toe walking: S1 root problems

• Xray: AP, lateral and maybe oblique views
  • after 2-4 week
  • always immediate for acute injury or if infection or tumor is suspected
  • changes of bulging disc bulging disc abnormalities present in 40% on normal pts
  • symptomatic pts also have changes in adjacent facet joints and soft tissue inflammation
• MRI: to confirm if necesssary (after 4-6 wks if surgery is contemplated)
  • degenerative discs with low water content will appear black 
  • make sure to include why test is being ordered so it will be weighed correctly

• Intervertebral disc is major source of most back pain
• Intervertebral disc Herniation or degeneration

• 95% at the 4th-5th disc spaces (L5 nerve root)
• Remainder at 3rd
• Normal aging causes changes in nucleus pulposus
• disc material begins to herniate into neural canal
  • usually posterolateral aspect of disc
• most common in 3rd and 4th decades (acutely) 

• Rare
• from a massive central disc herniation
• can produce perminant paualysis in lower extremities
• severly impaired blder and bowel fxn
• immediate eval and surgery
• can be caused 2° to a traumatic injury, from hematoma pressing on central canal

disc dz caused by EITHER herniation or degeneration can present in various ways: 

1. mild; no nerve root compensation

2. herniation with nerve root compensation

3. Cauda equina syndrome

4. chronic degenerative dz with or without leg sxs (intermittent back pain)

5. Spinal stenosis 

Bulging seen on MRI does not necessarily produce sxs

• low axial back pain (deep; achy)
• usually one sided
• aggravated by activity, relieved by rest (both axial and radicular pain)
• coughing, sneezing makes pain worse
• pt can ID the pain with a finger near the disc
• Pain may be referred to iliac crest or buttock
• Radicular pain can also occur, with or without axial pain
• restriction of low back motion
• bending toward affected side worsens pain (generally)
• local tenderness
• muscle guarding
• affected hip and knee kept in a slightly flexed position

• When disc protrudes far enough to press on nerve root
• intense pain
• pain in lower extremities presents in a dermatomal pattern (L3, L4, L5 most common)
• usually spreads over the buttock, passes down thigh and calf posteriorly or posteriolaterally, can go into foot

Paresthesias (numbness and tingling) common 

worse in distal extremity (often follows dermatome pattern)

• with pt lying on back, lift leg up with knee straight
• pain before 70° when affected leg is raised = + siatica
• pain when contralateral leg is raised = disc herniation

• a thick nerve structure formed by te joining of L4, L5, S1, S2, and S3 spinal nerve roots
• compression of any or all leads to sciatic pain

• conservative (most pts get better)
• Acute disc herniation with sig radiculopathy: 2-5 days bed rest if necessary (only time bed rest is suggested)
• Then, exercise program (consider PT for exercise 3xs week, include deep hear and massage)
• When supine, pt should keep hips and knees flexed (relieves pressure on spine)
• NSAIDs and moist heat (heat for chronic pain only)
• Narcotics may be necessary for severe sciatic pain
• Gradually resume activity as improvement allows
• Patients should be taught proper way to lift and bend over to avoid future problems

• If pt is not improved within 6 weeks: 
• Caudal or epidural cortisone injections (refer)
  • can help with residual radicular pain, but not axial spine pain
  • may not relieve leg pain if disc continues to press on nerve root
• most pts improve with conservative tmt, but it tends to recur

• Severe cases only 
• pts with major or progressive neuro deficits
• severe leg pain that has been present for > 6 weeks (<5% require surgery)
• removal helps leg pain and fxn, NOT spine pain (educate pt)
• if hx is+, MRI and EMG+, success with surgery is 95%
• no long term difference between conservative and surgical tmt
• sciatic nerve root pain does not automatically mean surgery, must persist after 2 wks complete bed rest but present for >6 weeks
• Only absolute emergent indication is cauda equina syndrome

S/S of cauda equina syndrome

• back pain
• bilateral sciatica
• saddle anesthesia
• motor weakness
• often incontinence

adults>40 yo have this often by Xray before sxs

significant thinning of disc + osteophytes

• Most tmt conservative:
  • NSAIDS
  • analgesics
  • rest
  • moist heat
  • lumbosacral corset
  • education
  • exercises
  • posture training
  • quit smoking
  • PT to address deconditioning
  • Leg pain: epidural pain blockers

• narrowing of spinal canal and nerve root foramina
• ↓ space for nerves and cord
  
• usually 2° to disc degeneration, facet joint arthritis, subluxation
• occasional due to congenitally small spinal canals
• leads to abnormal P on spinal nerve roots

• Hallmark: neruogenic claudication (painful cramping or weakness in the legs due to a necrologic problem)
  • low back pain
  • motor weakness
  • leg cramping
  • sensation of poor circulation in the extremities
• pt usually > 50
• aggravated by walking and extension of lumbar 
• Improvement with rest or flexion of spine (lean forward ie on shopping cart)
  • as opposed to vascular claudication impreves with rest : neuro claudication requires sitting (forward flexed position)
• Rarely presents with sphincter disturbances and muscle atrophy

Xray findings of spinal stenosis

usually shows degenerative changes throughout lower back

If surgery is contemplated : MRI

• Non-surgical usually 
• Reduce lumbar lordosis (inward curve at the base of spine)
• promote lumbosacral flexion (corset can help)
• NSAIDs, COX2s 
• analgesics
• hip flexion and abd strengthening exercises
• epidural pain blocks may help

• usually good
• serious neruo problems are unusual
• if they develop, refer to a surgeon with a special interest and education in spine

Facet syndrome

• can be a cause of chronic low back pain
• can become affected because disc thinning and often arthritis develops in them 
• facet joint articulation may become out of alignment (subluxation), which compresses the nerve 
• Usually has a long hx of chronic back pain that has not responded to traditional tmt

• local facet tenderness
• pain on bending to the affected side
• lumbar facet syndrome might cause referred pain to buttocks and thigh

• Inject with lidocaine plus steroid
• sometimes nerves to these joints have been severed with relief (if other methods don't work)
• Radiofrequency rhizotomy/neurotomy might be necessary to relieve pain and improve mobility
  • surgical de-nerving of the facet joint
  • needle with a small electrode placed into the facet joint under Xray monitor
  • electric current used to destroy the sensory nerves of the joint → pain relief

• Muscle or ligament injury commoly causes low back pain
• incomplete muscular tears
• ligament sprains
• both cause pain and tenderness over injured area (can radiate to buttock but not into leg)
• heals quickly (pain fro 2-3 days)
• brief rest and symptomatic tmt

• Previous chronic dz: heals slowly
• no improvement: 
  • obesity
  • poor muscle tone
  • smoking
  • poor work habith high heel shoes
  • no daily exercise
• often increase in lumpar lordosis
• causes increased strain on discs, ligaments and muscles
• obesity or pregnancy: usually poor abd muscle tone, so support of posture is poor, adds P to each disc

• Exercise program should be started, emphasizing postural exercises
• PT may help
• shour rest period (1-2 days)
• Mild analgesics (NSAIDs)
• Gradual return to activities
• Walking/aerobic activities started quickly to avoid deconditioning

Isthmic spondylolisthesis 

- Spondyollistesis: (usually in lumbar spine) one vertebra gradually slips over on another (usually forward)
- Most is due to spondylolysis: a specific defect in the connection between vertebrae, usually a fibrous defect in the pars interarticularis or isthmus of the vertebra (a tear or break, can occur acutely or due to chronic degeneration)
- Usually acquired, not congenital 
- Hereditary disposition: due to loading and extension stresses to lower back can cause an overuse fatigue fx (often b/l) at isthmus that does not heal
- most common at L5-S1

- if b/l, spondylolisthesis (forward displacement) can occur

• Can develop in teenage years
• symptoms many years later
• common in football players, structural abnormalities, gymnists

• spondylolysis can have symptoms even without spondylolisthesis
• both conditions associated with lumbar disc herniation (often asymptomatic)
• symptoms can begin gradually in 2nd or 3rd decades
• low back pain radiating into buttocks happens with activity and relieved by rest

• Guarding of lower part of back
• Spasm of parasternal muscles (esp in adolescent)
• many kids have no pain
• present with porstral deformity, abnormal gait
• increased lumbar lordosis
• might feel a step off in spinous processes of the lumbar spine
• tenterness in affected area
• hamstring tightness

• Adolescent: heal the stress fx, or to have a painless nonunion
• if no slippage: prolonged bracing and restricted activities for several months
• if no healing by 6 months, none will occur
• then, or in adult: rest, careful exercise program, hamstring stretching, wt loss, NSAIDs and lumbosacral orthosis

• may increase in degree
• gradual and stops by maturity
• further slippage in adulthood is rare
• if pt has intractable pain: surgery
  • spinal fusion and decompression

• From disc degeneration and narrowing
• if disc settling is uneven, spondylolisthesis can develop
• S/S: degenerative disc disease, sometimes with stenosis
• treat as for those conditions