DDX Low Back MT Review

DDX Low Back MT Review

Typical disc herniations occur in the paracentral zone (aka lateral
recess) and effect the traversing nerve root
Example a typical L2 disc herniation will compress the
traversing L3 nerve root
Know that a foraminal or far lateral herniation (or bone spur) will
compress the traversing nerve root
Example an L3 foraminal or far lateral disc herniation will
compress the exiting L3 nerve root

Nerve Fibers
Which nerve fibers carry pain signals from the disc
sinuvertebral nerves
Which nerve fibers carry pain signals from the facet joints
medial brain of the dorsal ramus
The outer periphery (one quarter) of the posterior and
posterolateral disc is actually wired for pain
The gray ramus communicans also carries nociceptive impulses
from the sinuvertebral nerve
Remember they run through the sympathetic chain (aka
sympathetic trunk) up to the sympathetic ganglia of L2
From there they travel back down that gray ramus
communicans, into the spinal nerve, and then blend in with
the incoming sensory messages of the sensory portion of
the nerve root

Know the difference between the differential diagnosis versus the main
working diagnosis
Differential diagnosis a diagnosis that is almost similar to the
main working diagnosis but not quite as much as the working
diagnosis
Main working diagnosis your current hypothesis of complaint
etiology; whats wrong with the patient
Primary diagnosis the most bothersome complaint or serious
complaint

Likelihood ratios
Sensitivity the probability of a positive test in patient who have
the disease
Tests that are highly sensitive are used as a screening test
to rule out disease
+ LR: sensitivity/ (1- specificity)
Specificity the probability of a negative test in patients who do
not have the disease
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DDX Low Back MT Review

Tests that are highly specific are used to rule in disease in

patients that are thought to really have the disease
- LR: (1-sensitivity)/specificity
Test with a very high positive LR ratio rules out disease if the test
is positive test
If a test has a very negative LR ratio, then it is good for ruling in
disease if the test is negative
Definitions it is the likelihood (or probability) that the patient
really has or doesnt have the disease/condition, give the positive
or negative test results
Can also determine the tests usefulness

Pretest probability
Can be calculated by using published probability studies, validate
the clinical protection rules as well as clinical experience and
judgment, the latter of which is more applicable for
chiropractors.
Certain line in the sand that needs to be crossed in order to
start treatment
Pretest probability and post-test probability has to be high
enough to cross the treatment threshold

What is a motion segment

vertebra, disc, vertebra sandwich; two adjacent vertebra and the
disc in between them
know the arches

vertebral canal zones

herniation occurs in one of the zones; which nerve gets
compressed
the traversing nerve roots (compressed for the paracentral
zone)
exiting nerve root which may be compressed either within
the neuro-foramen (neuro-foraminal zone)
lateral to that (the extra foraminal zone)

History MDS WRITE Medical Medication Poorly

M mechanism of injury
D date of injury
S subjective complaints, severity, sleep ability
W work ability
R radiation pain
I imaging history
T treatment history
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E emptying/holding ability of bowel/bladder

M medical hisotry
M - medication history
P progress: is the patient getting better or worse

HI PROs Never idle

H - history
I inspection
P - palpation
R - ROM
O orthopedic testing
N neurological testing
I imaging

Degenerative joint disease

The akas would-be osteoarthritits of the lumbar spine or
osteoarthrosis of lumbar spine
Not degenerative disc disease which is a condition of the intervertebral disc in which the disc becomes dehydrated (black and
T2 weighted MRIO imaging) because of cell death (no
proteoglycans to hold water) because of poor oxygen/nutrient
supply to the inside of the disc because the channels between
the vertebral endplates and the subchondral bone of the
vertebrae because clogged with new bone formation typically
because of wear and tear and micro instability
DJD of lumbar spine is associate with zygopophyseal joints and/or
other parts of the vertebral body

More anatomy
Floor vs. roof of spinal canal
Floor formed by the posterior vertebral bodies in the
posterior disc
Roof formed by the lamina and root of the spinous
process
Ligamentum flavum
Called yellow ligament because it has a high proportion of
elastic fibers, it is one of the major ligaments that holds the
posterior arch together and in order to remove a disc

DDX Low Back MT Review

herniation, this needs to be cut away because you cant

access the epidural space without cutting through it

11 causes of low back pain

Soft tissue/biomechanical-related injury
Spondylolysis/spondylolisthesis/laterolisthesis
Spinal stenosis
Scoliosis
Facet syndrome
Discogenic pain syndrome
Isolated disc resorption
Sacroilian syndrome
Piriformis syndrome
Myofasical pain syndrome/fibromyalgia/regional pain syndrome

Facet joint cysts

2 types
Synovial facet joint cysts
Ganglion facet joint cysts
Both capable of producing both low back pain (they become filled
with pain generating nerve fibers and are irritated from the
movement of the facet joint, like in the wrist) as well as real
radicular pain (sciatica) if they compress the traversing and/or
exiting nerve roots
Hence, they can perfectly mimic the signs and symptoms of the
disc herniation or lateral canal stenosis
Treatment
Conservative care (bed rest, NSAIDs, analgesics, PT)
Surgical laminectomy, facetectomy, flavectomy and cyst
excision

Scoliosis
Definition lateral spinal curve that exceeds 10 via Cobb angle
2 types
Structural - fails to straighten out with lateral bending
does not decrease in magnitude during lateral bending

radiographs into the apex of the curve. For example, a

50 scoliosis with the apex right decreases to 30 during
right side-bending is still considered a structural scoliosis
Non-structural - straightens out with lateral bending
adolescent idiopathic scoliosis - which means that the child was
diagnosed with scoliosis before the age of 18
know that adult de novo idiopathic scoliosis exists as well, which
typically occurs from severe degenerative change which results in a
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Nerves
sinuvertebral nerve is the one that carries pain signals from a torn

one-sided vertebral collapse, which in turn starts a chain reaction of

malposition vertebra, which results in the scoliosis
scoliosis has the potential to cause not only severe chronic low back
pain, but severe psychological sequelae from disfigurement. In some
cases (typically infants or young children) it can cause severe
cardiorespiratory complications and even, rarely, death
right sided curves more prevalent (apex to the right)

intervertebral disc
basivertebral nerve is the nerve that carries pain signals from irritated
and inflamed subchondral bone (the bone right above the vertebral
endplate
Both of these, are thought to be involved in patients with isolated
discrete absorption (well talk more about that later but know that
much)
pain travels (I think I set this above are ready) down the gray rami
communicantes (plural) to the sympathetic chain and then up the
sympathetic chain to the L2 sympathetic chain ganglia, back down the
gray ramus communicans and then into the spinal nerve and up

Scoliosis continued
there are several conditions that are strongly associated with the
development of scoliosis.
neuromuscular disease - cerebral palsy, polio, muscular
dystrophy
functional scoliosis - short leg, pelvic obliquity
inflammatory scoliosis - RA
translatory scoliosis - acute muscle spasm which may occur in
relation to facet problem, disc problem, SI problem, tumor, or an
injury to the muscle itself

Categories of idiopathic scoliosis (80% of all cases)

Infantile birth to 2.9 years
Juvenile 3 years to 9.9 years
Adolescent - 10 years to 17.9 years
Scoliosis is a three-dimensional best
Normal coronal
Sagittal
Axial vertebral positions
10X more likely than males as a right-sided main thoracic curve
Danger time beginning of the adolescent growth spurt (~10
12 yoa)
An untreated moderate lumbar lateral curve (30) can
almost double

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If it reached 50

in magnitude, surgery will be needed

for sure to prevent cardiovascular problems

Maximum dosages
Aleve (naproxen sodium) 110 Mg; 2 pills AM, Afternoon, 1 PM
Tylenol (acetaminophen) 3250 Mg
Advil (ibuprofen) 3200 Mg

Red flag findings ER

Saddle parasthesia
Progressive or severe neurological deficit
Foot drop
Cant heal or toe walk
Severe unrelenting pain
Not relieved by removing gravity (lying down, reclining)
Impaired bowel and/or bladder function
Medical emergency!!

Lenke classification system

6 curve types, 3 lumbar modifiers, 3 sagittal thoracic modifiers
Replaced the King system; however, the Lenke system still does
not take into account the rotational deformity of scoliosis
4 Lenke curves the curve has to be at least 25 to have a
chance to be included
Proximal thoracic: apex T3 T5
Main thoracic: apex T6 T11
Thoracolumbar: apex T12 L1
Lumbar: apex L2 L4
but when we categorize these, there are only three categories
proximal thoracic curve
main thoracic curve
thoracolumbar/lumbar curve
6 curve Types of AIS
Type 1 major thoracic curve (main T spine curve is major)
Type 2 double thoracic curve (T spine curve is major,
minor T spine curve)
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Type 3 double major curve (main T spine curve,

thoracolumbar is minor)
Type 4 triple major curve (major T spine and L spine
curve
Type 5 thoracolumbar curve is major
Type 6 thoracolumbar/lumbar-thoracic curve (main
thoracic curve is minor)

Lets do an example for a Lenke curve classification question:

*classify this curve. Given: upon supine lateral bending radiography is noted that
the main thoracic curve (36) reduces to 18 and the lumbar curve (68) reduces to
60.
*Thought process: only curves greater
than 25 during apex lateral bending
are counted in the rating system. In
other words, just because the curve is
over 25 in a neutral position does not
mean it is counted in the Lenke
classification system. Because if it
reduces to under 25, you do not
count it.*So in this example, the 36
main thoracic curve reduced to under
25 (18) and therefore does not
count. Therefore, all we have is a
thoracolumbar/lumbar curve which is
major and structural [remember any
major curve {i.e. the biggest coronal
curve} is automatically assumed to be
structural as long as is bigger than
25. So this would be a Lenke 5. Now
we have to add up the lumbar modifier
in their. Since the lumbar curve apex
which looks to be L1 (thats the
vertebra that is farthest away from the
midsagittal line) is completely lateral
to the midsagittal line (which is
officially called the central sacral
vertical line {CSVL}), this would be a
type C lumbar modifier
Answer - Lenke 5C.

Modic Changes
Vertebral body marrow changes, vertebral end plate changes
Specifically, know how they appear on MRI (T1 weighted and T2

weighted)
know which ones are potentially associated with gram-positive
anaerobic bacterial invasion (those would be the Modic type I)
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identify these if I put MRI images up

considered by many as a more severe form of DDD
etiology is thought to be from micro-trauma to the endplates with
micro or macro instability of the motion segment
types
type I sequelae of an acute or sub-acute inflammatory process
type II bone marrow in the sub-endplate is replaced by fat
type III indicates reactive sclerosis of the sub-endplate

Albert Study
randomized placebo-controlled trial
100 day course of antibiotic therapy was effective at reducing chronic
back and leg pain; it is certainly worth a try in patients who are
otherwise on track for a lumbar interbody fusion

Lateralisthesis
not safe to perform grade 5 manipulation on laterolisthesis or

DISH
spares the SI joints
starts in middle age
typically asymptomatic and accidentally discovered on radiographic

spondylolisthesis for that matter without taking a flexion extension

radiographs
you dont know whether or not it is stable and if you crack someone
with an unstable vertebra you might seriously injure the patient
(damage the nerve roots, the thecal sac, or spinal cord) and get sued

images
may present as complaints of stiffness

Neuros
neurological packages of the lower extremities
S1 = Achilles reflex, gastrocnemius strength, and lateral foot

dermatome
L5 = no clinically feasible reflex, top of the foot outside of the
leg dermatome (pain complaints region), and extensor hallucis
longus muscle strength

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L4 = inside of the leg and inside of the foot dermatome, patellar

reflex, and dorsiflexion of the ankle {remember this is the nerve
root is responsible typically for foot drop}

Spondylolysis
Break in the posterior arch of the vertebra, one of the most
common causes of low back pain in adolescent athletes
Usually occurs in the weakest portion of the posterior arch pars
interarticularis
Slip is usually anterior (anterolisthesis or spondylolisthesis) but
may also slip laterally (laterolisthesis)
typically occurs, whether symptomatic or not, in the first decade of life.
Over 50% of them worsen into a full-blown spondylolisthesis by the

third decade of life.

Approximately 25% of them become symptomatic with the passage of
time.
Considered an acquired stress fracture of the pars interarticularis
which may be secondary to a genetic component (i.e., a predispose
weakness of the pars interarticularis).
remember that a dysplastic spondylolisthesis is one in which there is
some type of genetic screw-up which results in a weak and/or
undersized pars interarticularis, zygapophyseal-joints, and/or vertebral
body, these are virtually never seen at birth or during infancy (0-3
years) and sometimes very difficult to see on radiograph and even MRI
The gold standard is the bone scan, which should only be used as a
last resort because it does introduce radioactive chemicals into the
person
remember that reactive sclerosis, which can be seen on CT, MRI, or
even radiographs sometimes, can often be a dead giveaway of an
underlying spondylolysis
Also remember that L5 is affected most often (85 95% of the cases)
remember the high risk sports: cricket, track and field throwing
events, weightlifting, football, gymnastics or something somewhere
an increased sacral base angle (>50) with an anterior weightbearing/malposition of the lumbar spine are considered high risk
factors for the development of spondylolysis.
a spondylolisthesis can develop a sharp point (called the beak) at the
fracture site which has the potential to stab the traversing nerve root
and therefore cause full-blown radicular pain and radiculopathy
Spondylolysis can also cause low back pain because of micro motion at
the fracture site

DDX Low Back MT Review

Spondy managment
never, never, never allow the patient to take nonsteroidal anti-

Degenerative spondylolisthesis
Know all about degenerative spondylolisthesis we are seeing more

inflammatories (NSAIDs) for suspected acute spondylolysis (fx healing

is an inflammatory process)
Why? Because as you may recall from your anatomy and
biochemistry, new bone formation (early on) involves an
inflammatory process and therefore if you snuff out the
inflammatory process with NSAIDs, you are significantly
decreasing the chances for that fracture (spondylolysis) to
naturally heal.
You should also not use grade 5 manipulation on a child with suspected
acute spondylolysis obviously, this is a stress fracture in you do not
manipulate fractures (unless you want to hurt the patient and get
sued). You can, however, work on core muscle strengthening but this
should be done more I symmetrically as you dont want to do a lot of
movement into a healing fracture, right
put the patient in an extension-limiting orthosis (a.k.a. brace) for 4 to
6 weeks. Although this is probably out of your scope, you could at least
recommend an electric bone stimulator which may be able to heal the
spondylolysis still considered experimental although it works on long
bone fractures.

and more these as the baby boomers get older.

Failure of the facets to stop natural anterior translation of the top
vertebra of a motion segment
They are failures of the zygapophyseal-joints to prevent natural
anterior translation. In other words, the facet joints are so degenerated
that they have lost the ability to prevent natural forward slip of the
vertebral body which occurs anytime you bend forward
In these patients, NSAIDs are okay, because they are not fractures,
their deformities or degenerative deformities of the facet joints
Another risk factor for the development of degenerative
spondylolisthesis is facet tropism i.e., zygapophyseal-joints that are
too sagittally orientated.

Isthmic Spondylolisthesis
Usually caused by a fracture of the pars interarticulairs
Stress fracture
Acute fracture
Elongated pars

Commonly seen at L5

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Be able to identify on MRI/CT

traversing nerve roots
nerve roots,
thecal sac
Should obviously know the difference between the superior articular

process and the inferior articular process on the same axial view.
also know where the pars interarticularis is on a sagittal MRI or CT
image or radiographic image for that matter.
know what a degenerative spondylolisthesis looks like an MRI and/or
CT axial the use.
Remember the inferior portion of the facet (i.e., the inferior articular
process) as well as the entire posterior arch for that matter slips
forward and leaves the superior articular process behind
These are very easy to identify if you look at the relationship between
the superior and inferior articular processes of the facet.

Likelihood Ratios
when a test has a positive likelihood ratio over 10.0, its very

powerfully rules in disease

When a test has a negative likelihood ratio of 0.1 or lower, it very
powerfully can rule out disease
if a patient is suspected of having a potentially life-threatening
fracture, and you only get to run one test, then you must rule out the
fracture by selecting the test with the lowest negative likelihood ratio
So if CT scan had a negative likelihood ratio of 0.05 and
radiographs had a negative likelihood ratio of 0.2, which one
would you pick? The answer is the CT scan (it has the lowest
number {0.05 is lower than 0.2, right} because if that test is
negative, then were virtually certain the patient does not have
a fracture and we can rest at ease. {This all should be review for
you, right?}

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