Spondylogenic diseases, back
pain
Josef Bednařík
General neurology questions:
26. Spine examination
27. Segmental, pseudo-radicular and radicular (C6-8, L3-5,
S1) syndromes
28. Epiconus, conus and cauda equina syndrome
Special neurology questions:
14. Back pain syndromes: acute, chronic, neck pain,
thoracic pain, low back pain - diagnosis, symptomatology
15. Spondylogenic radiculopathies and myelopathies:
diagnosis, symptomatology
16. Treatment of back pain syndromes (pharmacologic,
physiotherapy, surgery)
12.9.2021
Epidemiology
– 1st Most frequent cause of working disability in
people younger than 45 years
– 2nd Most frequent cause to visit the doctor
– 3rd Most frequent cause of surgery
– 5th Most frequent cause of hospital admittion
Epidemiology
– 1% of population is on sick leave
– 10-15% of sick leave days
– 1% of population is permanently disabled
How to classify spondylogenic diseases?
– According to the character of structural changes
▪Degenerative changes (spondylosis)
▪Non-degenerative structural changes (tumor, trauma,
inflammation, osteoporosis, maldevelopment)
▪Non-structural „functional“ changes
– According to clinical manifestation
▪Back pain syndrome
▪Pseudoradicular syndrome
▪Radicular syndrome
▪Myelopathy
▪Cauda equina syndrome
How to classify spondylogenic diseases?
According to involved part of the spine
– cervical
– thoracic
– lumbosacral
According to aetiology
– developmental (congenital)
– trauma
– infection
– tumors
– metabolic (osteoporosis)
– physical overload (occupational, sports)
How to classify spondylogenic diseases?
It is not possible to establish reliably the etiology of s.c.
simple back pain attacks in up to 85% of cases.
It seems to be useful and pragmatic to classify
spondylogenic syndromes according to clinical
manifestation a try to establish etiology.
Diagnostic algorithm in acute back pain: triage based on
different prognosis and different management
There exists a dilemma, how on one side not to burden a lot
of patients with otherwise benign and self-limited conditions
with sometimes risky diagnostic procedures and not
negligible side effects (and with respect to high frequency of
these patients also not to increase economical burden of
health care system), and on the other side not to postpone
causal treatment in a small group of patients with potentially
threatening disease that may lead to serious consequencies.
Diagnostic algorithm in acute back pain: triage based on
different prognosis and different management
Possible solution is an entry „triage“ (assortment), which could be
performed by a physician of the first contact (G.P.) in a patient
suffering from acute back pain. The triage is based on taking a
history, a basic neurological examination and on identification of „risk
factors“ increasing probability of serious structural spine disease or
damage - („red flags“).
Diagnostic algorithm in acute back pain: triage based on
different prognosis and different management
The triage could differentiate 3 big groups of acute back pain
with different prognosis and necessity to differentiate
diagnostic-therapeutic approach:
A. Up to 85% of acute back pain patients belongs to nonspecific,
„simple“ back pain, whose natural course is selflimited
and who usually recovers spontaneously. It is,
however, differentiate two other groups with more serious
prognosis and requiring different diagnostic and therapeutic
approach.
Diagnostic algorithm in acute back pain: triage based on
different prognosis and different management
B. Patients with compressive neurological syndromes due
to spondylosis, endangered by development of neurological
deficit: radicular syndromes (discogenic or osteogenic),
neurogenic claudication syndrome in multilevel lumbar
stenosis and cauda equina syndrome (usually due to medial
disc herniation). These compressive syndromes form about 8-
10 % of patients with low back pain.
Diagnostic algorithm in acute back pain: triage based on
different prognosis and different management
C. Patients with serious specific structural and usually
progressive disease of the spine (tumor, infection,
autoimmune inflammation, trauma, osteoporosis), that are in
danger of development of neurological deficit, but pain could
be the first symptom of serious, life-threatening, but potentially
treatable disease (about 5 % of back pain patients).
Identification of indicators (risk factors) of increased risk of
such a disease („red flags“) is considered as already verified
strategy.
Diagnostic algorithm in acute back pain: triage based
on different prognosis and different management
„RED FLAGS“:
– age >50 (55) yrs or <20 yrs (tumor); age >70 yrs
(suspicion of trauma);
– presence of primary extravertebral tumor (increased OR
from 0.7 to 9%), chronic inflammation (infection of kidney,
skin, lungs), or other serious disease (diabetes –
infection);
– long-term steroid treatment (trauma, infection); other
immunosupression (HIV, cytostatics – infection);
intravenous administration of drugs (infection);
Diagnostic algorithm in acute back pain: triage based on
different prognosis and different management
„RED FLAGS“:
– spine surgery or other invasive procedure (lumbar puncture,
periradicular therapy, epidural catheter - infection);
– loss of weight, unexplained fever (tumor, infection);
– history of trauma;
– pain lasting >1 month (especially tumor);
– pain of extraordinary intensity or lasting >1 month without
relief, resting, especially noctural pain (tumor, infection); pain
provoked by stance and decreasing while sitting; localized in
thoracic level; considerable local tenderness of vertebra
Diagnostic algorithm in acute back pain:
G.P. vs. specialist?
All current clinical guidelines on the management of back pain agree on
the attitude that patients with acute non-specific low back pain without
red flags, extravertebral disease or neurological deficit should be
managed by a doctor of the first contact, i.e. general practitioner for
approximately one month. A specialist should by contacted in case of
red flags, neurological deficit or if a patients doesnot respond to
standard treatment for at least one montht.
In all other cases patients should be managed by a specialist.
Whom will a patient with acute low back pain visit
in the USA?
– GP: 58,6%
– Ortopedic surgeon: 36,9%
– Chiropractist: 30,8%
– Osteopathy specialist: 13,8%
– Internist: 7,6%
– Rheumatologist: 2,5%
– Neurologist: 0!!!
Deyo R, Tsui-Wu Y-Jo. Descriptive epidemiology of low-back pain and its
related medical care in the United States. Spine 1987; 12:264-268.
Vertebromedullar
topography
Vertebrae Medullar segments and
roots
C1-7 C1-8 (+1)
Th1-6 Th1-6 (+2)
Th7-10 Th7-12 (+3)
Th 11 L5
Th 12 S2
L1-2 S3-5 (conus medullaris)
Bednařík et al. 2010
Vertebromedullar
topography
Vertebrae Medullar
segments and
roots
C1-7 C1-8 (+1)
Th1-6 Th1-6 (+2)
Th7-10 Th7-12 (+3)
Th 11 L5
Th 12 S2
L1-2 S3-5 (conus
medullaris)
Bednařík et al. 2010
Lumbar root
canal
Bednařík et al. 2010
Causes of radiculopathies
A. Compressive radiculopathies
1. Degenerative
▪Discopathy: herniations (+fragments)
▪Osteophytes - mostly uncovertebral (anterior part of the upper
recessus articularis)
▪Disc collapse
2. Non-degenerative: tumors, trauma, osteoporosis, developmental…
B. Non-compressive radiculopathies:
̶ herpes zoster, borreliosis, diabetes mellitus
Lumbar radiculopathy
A. Medial herniation
B. Mediolateral herniation
C. Lateral herniation
D. Foraminal herniation
E. Extraforaminal herniation
Bednařík et al. 2010
Topography of disc
herniations and injured
roots
L3
root
L5
root
L4
root
Bednařík et al. 2010
Dermatomes (areae radiculares)
Radiculopathy C5
– PAIN, SENSATION - neck,
shoulder
– STRENGTH – weakened arm
abduction
– REFLEXES: unelicited bicipital
reflex
Radiculopathy C6
– PAIN, SENSATION: shoulder,
lateral arm, forearm, thumb
– STRENGTH – weakened forearm
flexion
– REFLEXES: unelicited bicipital
reflex
Radiculopathy C7
– PAIN, SENSATION dorsal
aspect of arm,
forearm, hand dorsum, digit
II-IV.
– STRENGTH – weakened
forearm extension
– REFLEXES: unelicited
triceps reflex
Radiculopathy C8
– PAIN, SENSATION – medial
aspect of arm, forearm, digit IV-V.
– STRENGTH – weakened hand
muscles
– REFLEXES: unelicited flexor
digitorum reflex
Radiculopathy L4
– PAIN, SENSATION – anterior
aspect of thigh, medial aspect of
leg
– STRENGTH – weakened knee
extension
– REFLEXES: unelicited patellar
(knee) reflex
Radiculopathy L5
– PAIN, SENSATION – lateral
aspect of thigh, anterolateral
aspect of leg, dorsum of hand,
big toe
– STRENGTH – weakened foot
dorsiflexion
– REFLEXES: 0
Radiculopathy S1
– PAIN, SENSATION – gluteal
region, dorsal aspect of thigh, leg,
lateral aspect of foot, digit. II-V
– STRENGTH – weakened flexion
of foot
– REFLEXES: unelicited Achilles
tendon reflex
Diagnostic workup
–Clinical examination: pain characteristics and topography,
strength, sensation, reflexes, compressive maneuvers
–Radiograms (AP, lateral, oblique projections, dynamic scans)
–MRI
–CT
–Myelography, myelo/CT
–Electrophysiological exams (EMG, SEP, MEP)
Compressive root tests
Femoral nerve stretch test
– L4
Straight leg raising test
(Lassegue): L5 a S1
Adiga et al. McMaster Musculoskeletal Clinical Skills Manual De Lucena et al., 2010
Patrick-Faber test
Adiga et al. McMaster Musculoskeletal Clinical Skills Manual
It is positive if pain
arise from the hip or
sacroiliacal joint
Torg-Pavlov Index = a/b
(C5)
TA index < 0,82 =
congenital stenosis
RTG
Provided by Dept.Radiology, University Hospital Brno
LSS - myelography (radiculosacography)
– „Gold standard“
– Quantification of dural sac
compression (Porter 1992)
Provided by Dept.Radiology, University Hospital Brno
CT exam
Degenerative lumbar stenosis
Provided by Dept.Radiology, University Hospital Brno
CT exam: medial disc herniation L5/S1 (axial scan)
Provided by Dept.Radiology, University Hospital Brno
CT exam: lateral disc herniation L5/S1 (axial scan)
Provided by Dept.Radiology, University Hospital Brno
Myelo CT
Axial CT scan above and below block
Provided by Dept.Radiology, University Hospital Brno
Magnetic resonance
imaging: medial
herniation C6/7 with
cervical cord
compression (MR saggital
scan, T2W image)
Provided by Dept.Radiology, University Hospital Brno
Magnetic resonance
imaging: cervical cord
compression by dorsa
osteophytes at C5/6 and
C6/7 level (MR saggital
scan, T2W image)
Provided by Dept.Radiology, University Hospital Brno
MRI: paramedial sequestrated L5/S1 disc
herniation (MR saggital scan, T1W image)
Provided by Dept.Radiology, University Hospital Brno
MRI: paramedial L5/S1 disc herniation on the
left side (T1W image, axial scan)
Provided by Dept.Radiology, University Hospital Brno
MRI: left-sided paramedia L5/S1 disc herniation
(TW1 image, frontal scan)
Provided by Dept.Radiology, University Hospital Brno
MRI myelography: multisegmental
degenerative lumbar stenosis
Provided by Dept.Radiology,
University Hospital Brno
Cauda equina syndrome
–Sphincter dysfunction
–Sensation, pain: Saddle hypo/anaesthesia +
more proximal dermatomes
–Possible asymetry
–Flaccid paraparesis
–Positive compressive tests (Lassegue)
Conus medullaris syndrome
▪Sensation: saddle hypo/anaesthesia, no
pain
▪Sphincter disturbances
Degenerative (spondylotic) cervical myelopathy
(DCM)
Epidemiology: the most frequent cause
of lower paraparesis above the age of 55
years
Pathophysiology:
▪Cervical cord mechanical compression
(static, dynamic)
▪Vascular factor
▪Repetitive microtraumas
Provided by Dept.Radiology,
University Hospital Brno
Most frequent clinical symptoms and signs of
DCM
–Clumsy hands
–Disturbance of gait
–Cervical pain, radicular cervical pain
–Paretic signs
–Sensory signs
–Sphincter disturbance
MRI: degenerative cervical cord compression
(T1W image, axial scans)
Provided by Dept.Radiology, University Hospital Brno
Lumbar stenosis
Provided by Dept.Radiology, University Hospital Brno
Symptomatic lumbar spinal stenosis
–Neurogenic claudication
–Chronic cauda equina syndrome
Bednařík et al., 2010
Diagnosis of claudication
Clinical spectrum of claudications
Ischemic
claudications
Neurogenic
claudications
Venous
claudications
Bolest is in the
muscles of calf, thigh
or buttock
Pain is in the whole leg
and can be accompanied
by tingling, hypesthesia
or weakness
Pain in the whole
leg, that is „going to
burst“
Unilateral in
femoropopliteal,
bilateral in aorto-iliac
disease
Mostly bilateral Mostly unilateral
Gradual onset after
walding „claudication
distance“
Onset after standing or
walking, riding bicycle is
possible
Gradual onset after
beginning to walk
Pain is relieved by rest Relieved by bending over
or sitting
Relief on elevating
the leg
Absent/reduced
pulsations
Walking and stance in
semiflection
Oedema, varicose
veins, cyanosis
A Systematic Review for an American College
of Physicians (Chou et al. 2017): LBP
A Systematic Review for an American College
of Physicians (Chou et al. 2017): LBP
A Systematic Review for an American College of
Physicians (Chou et al. 2017): LBP: what is new?
▪ New evidence of no-effectivenes of paracetamol in acute LBP!!!
▪ New evidence of effectivenes of duloxetine in chronic LBP!!!
▪ NSAIDs have lower effect in acute and chronic LBP compared to
previously believed effect
▪ Myorelaxants has short-lasting effect in acute LBP, but cause sedation
▪ Opioids – moderate effect in chronic LBP
▪ Effect of systemic administration of corticosteroids doesnot seem to
be proved
▪ Generally, all proved effects are short-lasting and of mild or moderate
degree
Recommendation NICE 2016
(https://www.nice.org.uk/guidance/ng59)
– Consider NSAIDs with respect to side-effect profile and risk for an individial patient
– After NSAIDs administration monitor a patient, side effects and use
gastroprotection, use lowest-possible dose and shortest-possible duration of
treatment!
– Consider weak opioids (as monotherapy or in combination with paracetamol) in
case of ineffectiveness, intolerance or contraindication of NSAIDs!
– Don‘t use paracetamol in monotherapy!!
– Don‘t use opioids routinely for acute LBP
– Don‘t use opioids for chronic LBP
– Don‘t use SSRI, SNRI??? and TCA in LBP
– Don‘t use anticonvulsants (pregabalin, gabapenti) in LBP (except radicular pain)
Conclusions
Always consider the use of pharmacotherapy in LBP:
▪“most episodes of acute LBP are self-limited and not every
patient needs pharmacotherapy!
▪It is recommended to explain to patients benign character of
acute LBP episodes, expected benefit of pharmacotherapy and
possible side-effects
▪Risks of side effects of pharmacotherapy could overweight its
benefit!
▪Use non-pharmacological treatment?
Conclusions
In acute LBP after decision to start pharmacotherapy:
▪Short-lasting therapy, for necessary episode only, follow side
effects, instruct a patient!
▪Consider NSAIDs, non-benzodiazepin myorelaxants
▪In severe pain (even in chronic LBP) consider weak opioids and
their combination with paracetamol, strong opioids (oxycodon),
tapentadol
Conclusions
In chronic LBP:
▪Consider pharmacotherapy (complex problem, change of
regimen, exercise, yellow flags!!!)
▪In case of acute exacerbations of pain consider NSA, opioids
(weak, strong, tapentadol)
▪In case of a neuropathic component of pain consider
gabapentinoids, duloxetine, opioids, tapentadol, eventually in
combination with analgesics relieving nociceptive pain (NSAIDs,
paracetamol)
▪Short-lasting therapy!
Conclusions
As non-indicated procedures in LBP are currently considered:
▪Paracetamol in monotherapy
▪Myorelaxants in chronic LBP
▪Antidepressants (TCA, SSRI)
▪Long-term pharmacotherapy (especially opioids, NSAIDs)
▪Systemic administration of corticosteroids
Indications for surgical therapy
̶ Secondary lesions ofr diseases of the spine or spinal cord (if
possible)
̶ Acute cauda equina syndrome due to medial disc herniation
(within 24 hours)
̶ Compressive monoradiculopathies due to disc herniation
oradicular canal stenosis (refraktory to non-surgical therapy,
prominent neurological deficit)
̶ Degenerative cervical myelopathy (moderate-to-severe deficit,
progression of the deficit)
Lékařská fakulta Masarykovy univerzity
2021