Autonomically Mediated Pain-Autonomic Pain Syndromes
[…] Practice, 18(1), 87-93. doi:10.1111/papr.12573 Walters, E. T. (2018). How is chronic pain related to sympathetic dysfunction and autonomic dysreflexia following spinal cord injury? Autonomic Neuroscience-Basic & Clinical, 209, 79-89. doi:10.1016/j.autneu.2017.01.006 Zhao, J. L., Wang, Y. J., & Wang, D. J. (2018). The […]
Cervical and Thoracic Zygapophyseal Joint Arthropathy
[…] instances, severe facet joint arthropathy can lead to segmental instability and joint subluxation. There have been many cases of intra spinal synovial cyst communicating with the C1-C2 facet joints and subarachnoid space associated with rheumatoid atlantoaxial instability and associated myelopathic […]
Arthrogryposis
[…] a common concern of adult.2 Specific secondary or associated conditions and complications Associated conditions and complications include Anesthesia risk: Increased spinal cord injury risk because of underdeveloped first and second vertebrae (caution with anesthesia for surgery). Malignant hyperthermia. Increased risk for aspiration. […]
Complex Regional Pain Syndrome Part 2: Management and Treatment
[…] , confined to patients that respond to phentolamine tests. No significant differences on pain relief, and functional improvement. 22 4. Spinal cord stimulation Spinal cord stimulation directly stimulates the dorsal columns to modulate neuropathic pain. Good evidence to support spinal […]
Lumbar Spondylosis Without Myelopathy/Radiculopathy
[…] zygapophysial joints (z-joints) of the lumbar spine. Degenerative lumbar spondylosis is a term used to describe a “mixed group of spinal bone diseases related to degeneration of the lumbar motion segment and associated pathologies.”30 The term spondylosis is not used as a clinical diagnosis but rather as a term to illustrate spinal pathology. Spondylosis may be associated with low back pain (LBP) and is associated with numerous spinal pathologies including spinal stenosis (narrowing of the spinal canal), vertebral instability, degenerative spondylolisthesis, osteoarthritis and malalignment.29 Etiology Though the etiology of lumbar spondylosis remains unclear, many have characterized it as osteoarthritis of the spine. It is thought to result from cumulative stresses combined with repetitive microtrauma, leading to an imbalance between the synthesis and degeneration of cartilage. When combined with increased stresses placed on the vertebrae and ligaments, osteophytes and calcifications occur, respectively.1,3 Bone spurs, also known as osteophytes, most commonly occur along the anterolateral aspect of the lumbar vertebral body. Posterior vertebral osteophytes are rare but can cause impingement on the nerve roots or spinal cord. Lumbar spondylosis can also occur due to new bone formation in areas where the annular ligament is stressed over time.29 Epidemiology including risk factors and primary prevention The prevalence of radiographic spondylosis increases with age.4,5 It is present only in a small percentage of the population in the first few decades of life but is relatively common by the age of 65. In those with LBP, the prevalence ranges from 7% to 75%, depending on the diagnostic criteria.6 Despite its frequency in patients with LBP, there is no validated correlation between the radiographic findings of lumbar spondylosis and presence of LBP. In the United States, approximately 80% of individuals older than 40 years old were found to have lumbar spondylosis, contrasted to3% of individuals aged 20-29 years.5 Recent studies have shown a positive correlation with the CC genotype of the transforming factor B1 gene and postmenopausal women.31 Risk factors Age is the greatest risk factor for lumbar spondylosis, but other risk factors including disc desiccation, previous injury, joint overload from malalignment and/or abnormal z-joint orientation, as well as genetic predisposition have been identified.2 Studies evaluating the role of body mass index, level of activity and gender on the incidence and severity of lumbar spondylosis do not show a clear correlation.5,7 Patho-anatomy/physiology Some investigators believe that lumbar spondylosis is due to a “degenerative cascade” that is initiated by intervertebral disc desiccation.8 The degenerative changes which characterize lumbar spondylosis are thought to be due to cumulative stresses on the annular ligaments which then form (i.e., marginal osteophytes).29 Failure of annulus and nucleus collagen cross-linking and the discs’ inability to retain water results in stiffening of the cartilaginous and capsular structures, further restricting z-joint mobility causing earlier and more advanced degenerative changes. This is particularly true at the L4/L5 and L5/S1 levels likely because of their proximity to the fused sacral segments.1,3 Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time) Although variable, most patients experience a benign clinical course. Studies have shown the following: radiologic spondylosis directly increases with age, irrespective of pain.9 spondylosis was shown to be equally present in those with and without LBP.2 no correlation between the magnitude of z-joint arthropathy and the severity of pain.6 Thus, progression is variable and unpredictable, and therefore difficult to study, but seems to be most closely linked to aging. Specific secondary or associated conditions and complications Z-joint hypertrophy in combination with ligamentous redundancy from disc desiccation may contribute to central canal, lateral recess and neuroforaminal stenosis. The increase in translational forces from disc desiccation, combined with the z-joints’ decreased ability to resist these factors, may also result in spondylolisthesis. Clinically, these changes can cause lumbosacral radiculopathy and neurogenic claudication. Disuse atrophy of the erector spinae and multifidi muscles secondary to pain-limited spine motion can also occur. Essentials of Assessment History As mentioned previously, lumbar spondylosis refers to certain radiographic findings that do not rely on clinical symptoms for diagnosis. However, in some patients with acute, subacute or chronic LBP, the radiological changes which make up lumbar spondylosis can be potential pain generators. Patients with lumbar spondylosis often complain of axial lumbosacral back pain with potential nociceptive input from the sacroiliac joints, overlying myofascial structures, intervertebral discs, nerve roots, and facet joints.30 Pain may refer unilaterally, bilaterally, or to the contralateral buttock, hip, groin and thigh regions; although, typically, it does not extend past the knee.6,10 The pain tends to worsen with extension, rotation and standing and is better with lying down and lumbar flexion.10 By definition, the term lumbar spondylosis is not associated with a neurologic deficit. However, spinal stenosis, spondylolisthesis, lumbar disc herniation and radiculopathy are known to be associated with neurological deficits. This is why it is imperative for the clinician to ask about weakness, gait and balance and bowel/bladder function when assessing patients with lumbar spondylosis. There are several validated outcome measures for grading functional limitations including the McGill Low Back Pain Scale, Oswestry Disability Index and the Medical Outcomes Study 36-Item Short-Form Health Survey.11 These should typically be administered at every office visit for following the patient’s progression. Physical examination A systematic review revealed that most physical exam maneuvers have limited or no diagnostic validity for spondylosis.6 Paraspinal tenderness is the only physical exam maneuver that seems to correlate with z-joint arthropathy, but not with high diagnostic confidence. Although classically felt to diagnose z-joint pain, joint loading with pain on extension and ipsilateral rotation has not been shown to consistently correlate with spondylosis.12,13 The pain distribution of lumbar spondylosis may overlap with other clinical entities. A comprehensive physical exam that includes evaluation for radiculopathy, including dural tension signs, as well as hip and sacroiliac joint provocative maneuvers can help guide clinical decision making. Neurologic deficits seen with lumbar nerve root compression should be evaluated through muscle, sensation, reflexes, gait, and balance testing. Discogenic pain is exacerbated when the patient is asked to repeatedly bend forward or when the patient is sitting up and one leg is placed in a flexed position by the examiner. Laboratory studies Although laboratory studies are not routinely indicated, C-reactive protein, sedimentation rate, and a complete blood count, may be ordered if there is clinical suspicion for conditions such as malignancy, infection or rheumatologic disease. Imaging Lumbar spondylosis is visible on multiple imaging modalities, including plain radiographs, magnetic resonance imaging (MRI) and computed tomography (CT) studies. However, as spondylosis on imaging does not constitute a cause for LBP, imaging is typically ordered to rule out other disorders.13,14,15 Plain radiographs are not sensitive for detecting early z-joint arthropathy or spondylosis but are often obtained. Lateral views are important for sagittal alignment and to assess for spondylolisthesis. If present, patients should undergo flexion and extension radiographs to rule out segmental instability which may necessitate earlier surgical consultation. MRI is generally not needed but is useful for evaluating the soft tissues and neural elements within the spine, especially to rule out neuroforaminal stenosis in patients with concomitant leg pain. The presence of small amounts of fluid or synovial cysts within the z-joints may be physiologic or may represent instability and/or infection within the lumbar spine, and therefore would warrant further work up and/or treatment. However, this is beyond the scope of this article. CT is typically utilized when an MRI is unobtainable, if fracture is suspected or for the assessment of pseudoarthrosis. It can also be helpful in identifying synovial cyst borders with implications for surgical vs percutaneous treatment.34 Supplemental assessment tools Diagnostic Injections Given the low correlation of radiographic spondylosis with axial low back pain, the only means for an accurate diagnosis of symptomatic lumbar spondylosis secondary to facet arthropathy are controlled diagnostic blocks of the medial branch nerves that innervate the z-joints.16 This assumes that the patient’s pain generator(s) are the z-joints and not the intervertebral discs. Each z-joint has dual innervation from the medial branch of the dorsal ramus of the spinal nerve at the corresponding level and the level above. To treat the pain associated with a specific z-joint, both nerves must be targeted. Several key principles exist for diagnostic medial branch blocks: Because of the inaccuracy of landmark guidance, all blocks should be performed utilizing image guidance. Both fluoroscopic and ultrasound guidance have been described in literature.34 False positive blocks occur at a high rate of 17% to 41% in the lumbar spine, thus necessitating a second control block for confirmation of the diagnosis. Ideally, the two injections should be performed with anesthetics of differing duration. Concordant pain relief (>1h with lidocaine and >3h with bupivacaine hydrochloride), greatly enhances the sensitivity and specificity of the injections.13 The greater the percentage of pain relief […]
Ethical Issues Commonly Managed During Rehabilitation
[…] Description Physiatrists are rehabilitation physician specialists trained to care for patients with complex medical conditions, including brain injury, neuromuscular disorders, spinal cord injury, musculoskeletal injuries, pain syndromes, and cardiopulmonary disorders. As leaders of interdisciplinary teams, physiatrists are skilled in actively engaging multiple […]
Osteoporosis in Rehabilitation
[…] given the lifelong nature of the illness, genetic counseling opportunities, and more specific treatment recommendations.25 Spinal cord injuries Osteoporosis after spinal cord injury (SCI) is extremely common with ~50% of complete SCI patients developing osteoporosis at 1 year post injury with longer […]
Lumbar Spondylolisthesis
[…] and bladder incontinence, saddle anesthesia, and/or sexual dysfunction. Rarely, traumatic grade V spondylolisthesis or spondyloptosis rostral to L2/L3 results in spinal cord injury.14 Essentials of Assessment History Patients typically complain of diffuse and dull axial lower back pain with or without lower limb radiation.1,15 Patients with nerve or cord involvement may have sensory disturbances and/or weakness. Radiculopathy, develops insidiously because of a combination of vertebral subluxation and associated disk degeneration, causing foraminal and/or central stenosis. System review should assess for symptoms indicating neurologic deficits, CES or cord injury such as stool and urinary continence, and other pathologic conditions. Sexual dysfunction may be observed in patients with LS but is frequently under-reported.16 Spondylolysis is the most commonly identified cause of back pain in children. Activity-related pain or specific traumatic event should be queried2 and include a detailed sports-specific history in athletes. Physical examination Inspection may reveal paraspinal hypertrophy, increased lumbar lordosis, or postural changes, such as a shortened waistline or flattening of the buttocks.1,15 Evaluate spinal range of motion and alignment. A palpable lumbar step-off is a very specific finding but is more often seen with Grade 3 and Grade 4 LS. Dural tension signs are typically negative although approximately half of adult patients with symptomatic IS will have a positive straight leg test.11 Focal neurologic deficits, such as weakness, sensory loss, or diminished reflexes, may be seen secondary to radiculopathy. Hamstring contractures are common in children.15 If there is clinical concern for CES secondary to LS, perform a rectal exam for sensation and tone and always evaluate for upper motor neuron signs. Functional assessment Gait evaluation may reveal a compensated extended lumbar spine position to relieve symptoms, although hyperextension and rotational motions may cause pain, especially during single-limb stance.1,2 Measures for assessing LS include the Oswestry Disability Index, Short Form of Medical Outcomes, and visual analog scale.10 These measures are not specific to LS but may be applied to other musculoskeletal conditions as well. Imaging Abnormal imaging findings in asymptomatic patients are common. Weak abdominal musculature, paraspinal muscle hypertrophy, lumbar hyperlordosis, slipping or step-off on palpation and inspection, hamstring muscle spasm, pain with lateral trunk flexion-extension and with double leg raising were found to be correlated with radiological assessment of LS.17 Initial plain radiographs are appropriate for these cases of suspected LS. Oblique views may better visualize a PI fracture2,15, although utility of oblique views in adolescents has been questioned by at least one study.18 Standing radiographs with flexion and extension are ideal to image the weight-bearing spine in dynamic positions, allowing identification of unstable spondylolisthesis if there is a change in severity grade.19 Normal values have been obtained in asymptomatic volunteers for passively performed flexion-extension and lateral bending in the lumbar spine, providing analysis of segmental rotation and translation.19 Computed tomography (CT) can better visualize spinal bony anatomy and also rule out other pain-contributing factors or tumors. Oblique plain films and CT do result in increased radiation exposure. Consider magnetic resonance imaging (MRI) in patients with signs or symptoms of radiculopathy.1 Instability can be suggested by MRI demonstrating large fluid-filled facet joints with increased signal on T2 axial images. Large facet joint effusions (>1.5mm at L4-5) are highly predictive of DS, even in the absence of findings of measurable listhesis on supine MRI. […]
Differential Diagnosis and Treatment of Visceral Pain in the Pelvis and Abdomen
[…] feeling of impending doom). Patho-anatomy/physiology The cell bodies for the sympathetic nervous system originate from the intermediolateral column of the spinal cord between T1 and L2/3. The paravertebral sympathetic ganglia are arranged in two chains spanning from the skull to […]
Incorporation of Prevention and Risk Factor Modification in Rehabilitation
[…] independent measure scores, diagnosis of stroke, brain injury, amputation, neurologic disorders (Parkinson’s disease, multiple sclerosis, Guillain-Barre, myopathy, peripheral neuropathy), and spinal cord injury.5 There is insufficient evidence for stand-alone screening tools to identify risk of falls among rehabilitation patients. St. Thomas Risk […]