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Toronto Notes 2019
Spine
Orthopedics OR25
DEGENERATIVE DISC DISEASE
• lossofvertebraldischeightwithageresultingin: ■ bulging and tears of annulus fibrosus
■ change in alignment of facet joints
■ osteophyte formation
Mechanism
• compressionovertimewithage
Clinical Features
• axialbackpainwithoutradicularsymptoms • painworsewithaxialloadingandflexion
• negativestraightlegraise
Investigations
• X-ray,MRI,provocativediscography
Treatment
• non-operative
■ staying active with modified activity
■ back strengthening
■ NSAIDs
■ doNOTtreatwithopioids;noprovenefficacyofspinaltractionormanipulation
• operative–rarelyindicated
■ decompression±fusion
■ no difference in outcome between non-operative and surgical management at 2 yr
SPINAL STENOSIS
• narrowingofspinalcanal<10mm
• congenital(idiopathic,osteopetrosis,achondroplasia)oracquired(degenerative,iatrogenic–post
spinal surgery, ankylosing spondylosis, Paget’s disease, trauma)
Clinical Features
• ±bilateralbackandlegpain
• neurogenicclaudication
• ±motorweakness
• normalbackflexion;difficultywithbackextension(Kempsign) • positivestraightlegraise,painnotworsewithValsalva
Investigations
• CT/MRIrevealsnarrowingofspinalcanal,butgoldstandard=CTmyelogram
Treatment
• non-operative
■ vigorous physiotherapy (flexion exercises, stretch/strength exercises), NSAIDs, lumbar epidural
steroids • operative
■ indication: non-operative failure >6 mo ■ decompressive surgery
Table 16. Differentiating Claudication
Aggravation
Alleviation Time Character
Neurogenic
With standing or exercise Walking distance variable
Change in position (usually flexion, sitting, lying down) Relief in ~10 min
Neurogenic ± neurological deficit
Vascular
Walking set distance
Stop walking
Relief in ~2 min Muscular cramping
MECHANICAL BACK PAIN
• backpainNOTduetoprolapseddiscoranyotherclearlydefinedpathology
Clinical Features
• dullbackacheaggravatedbyactivityandprolongedstanding • morningstiffness
• noneurologicalsigns
Treatment
• symptomatic(analgesics,physiotherapy)
• prognosis:symptomsmayresolvein4-6wk,othersbecomechronic
Cauda equina syndrome and ruptured aortic aneurysms are causes of low back pain that are considered surgical emergencies