Josef Bednařík
Department of Neurology, University Hospital
Brno and Faculty of Medicine, Masaryk
University Brno
8.11.2019
Spondylogenic diseases, back pain
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 SYNDROMES
 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“, who could perform a
physician of the first contact with 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 diagnostictherapeutic
approach:
A. Up to 85% of acute back pain patients belongs to non-specific,
„simple“ back pain, whose natural course is self-limited 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, ie 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 monthtandardní léčbu.
In all other cases a 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.
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
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
NONINVASIVE TREATMENTS FOR ACUTE, SUBACUTE, AND CHRONIC LOW
BACK PAIN: A CLINICAL PRACTICE GUIDELINE FROM THE AMERICAL
COLLEGE OF PHYSICIANS (QASEEM ET AL. 2017)
Acute/subacute LBP:
 Start with non-pharmacological treatment
 If pharmacological treatment is necessary, consider NSAIDs or myorelaxants
Chronic LBP
 Start with non-pharmacological treatment
 If non-pharmacological treatment is ineffective, consider NSAIDs, tramadol,
duloxetin.
 If ineffective, consider opioids with respect to their risks
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 procerures 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
EPIDEMIOLOGY
 1. Most frequent cause of working disability in
people younger than 45 years
 2. Most frequent cause to visit the doctor
 3. Most frequent cause of surgery
 5. 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
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)
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)
LUMBAR ROOT
CANAL
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
TOPOGRAPHY OF DISC
HERNIATIONS AND
INJURED ROOTS
L3
root
L5
root
L4
root
Dermatomes (areae radiculares)
RADICULOPATHY C5
 PAIN - neck, shoulder
 SENSATION – shoulder
 STRENGTH – weakened arm
abduction and forearm flexion
 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
L4 L5, S1
PATRICK’ TEST
TORG-PAVLOV INDEX = A/B
(C5)
TA INDEX < 0,82 =
CONGENITAL STENOSIS
RTG
LSS - MYELOGRAPHY (RADICULOSACOGRAPHY)
 „Gold standard“
 Quantification of dural sac
compression (Porter 1992)
CT EXAM
DEGENERATIVE LUMBAR STENOSIS
CT EXAM: MEDIAL DISC HERNIATION L5/S1 (AXIAL SCAN)
CT EXAM: LATERAL DISC HERNIATION L5/S1 (AXIAL SCAN)
MYELO CT
Axial CT scan above and below block
MAGNETIC RESONANCE
IMAGING: MEDIAL
HERNIATION C6/7 WITH
CERVICAL CORD
COMPRESSION (MR
SAGGITAL SCAN, T2W
IMAGE)
MAGNETIC RESONANCE
IMAGING: CERVICAL CORD
COMPRESSION BY DORSA
OSTEOPHYTES AT C5/6
AND C6/7 LEVEL (MR
SAGGITAL SCAN, T2W
IMAGE)
MRI: PARAMEDIAL SEQUESTRATED L5/S1 DISC
HERNIATION (MR SAGGITAL SCAN, T1W IMAGE)
MRI: FORAMINAL L4/5
DISC HERNIATION
(SAGGITAL SCAN, T1W
IMAGE)
MRI: PARAMEDIAL L5/S1 DISC HERNIATION ON THE LEFT
SIDE (T1W IMAGE, AXIAL SCAN)
MRI: LEFT-SIDED PARAMEDIA L5/S1 DISC HERNIATION
(TW1 IMAGE, FRONTAL SCAN)
MRI MYELOGRAPHY: MULTISEGMENTAL
DEGENERATIVE LUMBAR STENOSIS
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
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)
LUMBAR STENOSIS – ANATOMICAL
CLASSIFICATION
1. Central stenosis
1. 1.1. Anteroposterior (usually congenital
2. 1.2. Transversal (rarely congenital)
2. Lateral stenosis (root canal
stenosis)- degenerative
2.1. Stenosis of lateral recessus (medially to
pedicle)
2.2. Foraminal stenosis (caudally to pedicle
2.3. Extraforaminal stenosis (laterally to pedicle)
LSS – ETIOLOGICAL CLASSIFICATION
1. Congenital (developmental)
2. Acquired
2.1. Degenerative
2.2. Combined congenital and
degenerative
2.3. Iatrogennic
(postlaminektomic)
2.4. Spondylolythic
2.5. Posttraumatic
2.6. Various (Paget disease)
SYMPTOMATIC LUMBAR SPINAL STENOSIS
 Neurogenic claudication
 Chronic cauda equina
syndrome
DIAGNOSIS OF CLAUDICATION
COCHRANOVA DATABÁZE: FARMAKOTERAPIE BOLESTÍ ZAD
Typ
léčby
Cílová skupina
Aktuali-
zace
Průkaz efektu
NSA LBP 2008
ANO: krátkodobý efekt u akutní LBP bez kořenové symptomatiky, síla efektu je malá.
NE: větší účinnost jednoho typu NSAID oproti jinému. COX-2 inhibitory mají méně nežádoucích
účinků oproti klasickým NSAID, ale vyšší kardiovaskulární toxicitu
NSA
Neuropatická bolest u
LBP
2015
NE: efekt na snížení bolesti
NSA Chronická LBP 2016
ANO: průkaz nízké kvality efektu oproti placebu na bolest a mírného efektu na disabilitu
NE: rozdíl v účinnosti i bezpečnosti jednotlivých NSA
NSA Ischias 2016
ANO: průkaz nízké kvality na celkové zlepšení
NE: průkaz efektu na bolest
Myorela-
xancia
Nespecifické LBP 2004
ANO: efekt u akutní LBP (ne-benzodiazepinová myorelaxancia)
NE: efekt u chronické LBP; větší účinnost oproti NSA či jiným analgetikům
Antidepre-
siva
Nespecifické LBP 2008 NE: efekt u chronické LBP
Opioidy Chronická LBP 2013
ANO: průkaz nízké až střední kvality krátkodobého efektu na bolest a funkci
NE: rozdíl v efektu oproti NSA nebo antidepresivům
Paracetamol LBP 2016 NE: lepší efekt než placebo u akutní i chronické LBP v monoterapii
Tapentadol
Chronická
muskuloskeletální
bolest
2015
ANO: efekt na redukci bolesti oproti placebu a oxykodonu; klinický význam je nejistý; lepší
bezpečnostní profil oproti oxykodonu