The Clinician's Guidebook to Lumbar Spine Disorders: Diagnosis & Treatment

By Donald Steven Corenman

As both a spine surgeon and chiropractor, Dr Donald Corenman has developed a comprehensive understanding of lumbar disorders and conditions. His more than thirty years of practice on both sides of the fence have taught him that the treatment options expand when the disorder is well understood. This book covers the whys and wherefores of all lower back and leg pain management from chiropractic and physical therapy to surgery and is presented in a logical and easy to understand manner.

• Language: English
• Publisher: AuthorHouse
• Release date: Oct 11, 2011
• ISBN: 9781463487607

Donald Steven Corenman

So where do I come from and why do I find myself writing this book? I didn’t start my life with the intent to become a spine expert. My life circumstances have led me serendipitously into this field. I started out 30 years ago not knowing what to do in life. My cousin became a chiropractor and I thought it would be interesting, so, after college. I applied to the Los Angeles College of Chiropractic. I was promptly rejected which started my competitive juices flowing. Being somewhat stubborn, I decided to help them change their minds. After some convincing, they agreed to let me in. Four uneventful years later, I had my degree in hand and attempted the art of healing. Well, I helped some patients but didn’t help others. The reasons why I was successful at treating patients were murky as my understanding of the spine was incomplete. I decided to take a residency in Chiropractic Orthopaedics. This was actually about 3 years of weekend education while I was still practicing standard chiropractic. My knowledge base grew but I was still unsatisfied with some of my results and the holes in my understanding. I made the decision to go to medical school. I thought that after four more years of education, I thought I would have a mastery of spine and the human body. Convincing a medical school that a chiropractor should be educated in the allopathic (traditional) model was a much greater challenge than getting into chiropractic school. After some interesting travels and experiences, Wayne State University in Michigan accepted me (bless their hearts). As you can see, at the time, forethought of planning was not my strength. I failed to take into consideration that after medical school, there is still a five year orthopaedic residency and then a one year spinal disorders fellowship to consider. Ten years after starting with medical school, I was finally finished (or so I thought). It took me 3 more years after being on staff at the University of Colorado lecturing and teaching residents and fellows to put my experience into perspective and to understand how the two disparate fields I learned were complimentary and synergistic. Finally, the experience at the Steadman Clinic has been very fulfilling to allow me to mature to this point. I continue to think I have finally “put it all together” but I still learn many new pearls every day.

Book preview

The

Clinician’s Guidebook

to

Lumbar Spine Disorders

Diagnosis & Treatment

DONALD STEVEN CORENMAN, M.D., D.C

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AuthorHouse™

1663 Liberty Drive

Bloomington, IN 47403

www.authorhouse.com

Phone: [phone]

© 2011 by Donald Steven Corenman, M.D., D.C. All rights reserved.

No part of this book may be reproduced, stored in a retrieval system, or transmitted by any means without the written permission of the author.

First published by AuthorHouse 11/07/2011

ISBN: 978-1-4634-8762-1 (sc)

ISBN: 978-1-4634-8761-4 (hc)

ISBN: 978-1-4634-8760-7 (ebk)

Library of Congress Control Number: 2011916517

Printed in the United States of America

Any people depicted in stock imagery provided by Thinkstock are models, and such images are being used for illustrative purposes only.

Certain stock imagery © Thinkstock.

This book is printed on acid-free paper.

Because of the dynamic nature of the Internet, any web addresses or links contained in this book may have changed since publication and may no longer be valid. The views expressed in this work are solely those of the author and do not necessarily reflect the views of the publisher, and the publisher hereby disclaims any responsibility for them.

Contents

ACKNOWLEDGMENTS

INTRODUCTION

The Basics of Diagnosis and Treatment

Terminology

The History of the Sources of Back and Leg Pain: Pain Generators

The Anatomy and Function of the

Lumbar Spine

Pathophysiology of the Disc

Nerve Anatomy and Physiology

Pain

Typical Disorders that Cause Back and Leg Pain

Scoliosis and Kyphosis

Inflammatory, Infectious and Inherited Diseases of Nerves that Cause Leg Pain

Rheumatological Conditions (Spondyloarthropathies) and Fibromyalgia

Osteoporosis

Thoracolumbar and Lumbar Fractures

Mimics of Degenerative Disc Pain

Symptom Origins (Thinking Forward and Backward)

Specific Disease Processes and Associated Symptoms

The Art of Taking a Proper History

Physical Examination of the Lower Back and Lower Extremities

Interpreting X-Rays

EMG/NCV—Electromyograms and Nerve Conduction Studies

Treatment of Mechanical Lower Back Disorders

Alternative Care for Low-Back Pain

Chronic pain, Depression, and the Autonomic Nervous System

Medications: Their Use and Misuse

Injections: Diagnostic, Therapeutic, Rhizotomies, Idett, Nucleoplasty, and Discograms

Surgical treatment

How to Pick the Right Referral Clinician

PERSONAL HISTORY

ACKNOWLEDGMENTS

To Kim, Jessica, Steven, Samantha—thank you for your patience while I typed away

To Charmaine Bernhardt—your illustrations will light up the world of spine—many thanks

To Eric Strauch—thanks for looking over my shoulder and helping my poor syntax

To Dr. Marc Treihaft—thank you for your help reviewing the chapter on EMG/NCV

To Dr. Jay Kaiser—thank you for your help reviewing the X-ray chapter

To all my patients—thank you for your trust

Dear Reader—If you are interested in learning more about the cervical spine or reviewing surgical videos, please visit NeckandBack.com. The Clinician’s Guidebook for Cervical Disorders will be available in one year as long as my typing fingers hold out and Charmaine will still work with me.

Illustrations by Charmaine Bernhardt

Cover Art by Jessica Corenman

INTRODUCTION

Lower back pain is the second most common reason to visit a doctor, right behind pulmonary symptoms. Disorders of the lumbar spine force American society to expend fifty billion dollars a year. With regards to productivity, low back pain is the most costly problem in the industrial world. Eighty percent of the population will have disabling back pain at one time in their lives.

There are countless books regarding how to diagnose and cure the back. Some are accurate and others have significant misinformation. Many texts always seem to boil down to the fact that there is no real way to fully understand the causes of back or leg pain and then give a standard treatment protocol for all spine problems. This concept is simply incorrect. Almost all pain and dysfunction that the spine generates can be diagnosed and treated. The academic texts, even though complete are complex, difficult to understand and interpret.

The irony is in medical school, there is little time spent dealing with the education of medical students regarding the causes and treatment of lower back disorders. Chiropractic schools and physical therapy schools have much more emphasis on this subject, but the information presented can still be incomplete.

I have been involved with spine care for thirty years. Over this period, I have struggled to simplify many of the concepts of anatomy, physiology, and pathology so that knowledge can be used to educate patients on a daily basis. Since I had to break things down into small logical bites for myself, I thought it might be worthwhile to convey these ideas to other clinicians. Using this book should allow you to understand and master lumbar spine disorders and take the mystery out of the spine.

Reading this book will give a reasonable understanding of why problems occur and how to care for them using a treatment algorithm, but not the specifics of how many repetitions of what specific exercises to do. This is not a cookbook. You should be able to grasp the basic concepts and then use logic to design your own programs. This tome will direct you how to understand which exercises may be of benefit and which ones could be harmful. It is also designed to help to understand the role of surgery and will allow you to question those surgeons as to the right procedure.

For many patients, the knowledge of why they have spinal pain that will not put them in a wheelchair or cause paralysis may be enough to keep them from worrying about their back. This book will give you the tools to understand what the patient’s diagnosis is to then educate them. If you want to go further, this book will give you some tools to treat their disorder or find the referral source to help you with treatment.

I have no doubt that some spine-care experts may read this book and have problems with the liberties I have taken to simplify these subjects. Making a complex subject easy to understand requires some shortcuts and poetic license. I do believe this book is accurate and accessible. I hope I haven’t offended anyone, but I can withstand some criticism.

The knowledge of the spine chemically and mechanically is expanding at a great pace. Spine care may be significantly different ten years from now as it has changed in the last ten years. This book will need to be edited significantly in the years to come.

1

The Basics of Diagnosis and Treatment

The successful diagnosis and treatment of spinal disorders is defined by the patience, education, and experience of the examiner. The root factor is a correct understanding of the diagnosis and what can be done to manage or cure the disorder. There is almost always a treatment answer to a spinal problem. A majority of the time, management is the key. Management can include home exercises, activity avoidance and alteration, a guided physical therapy program with core strengthening, chiropractic care, medications, and ergonomics. Sometimes surgery can be an option, and occasionally, it is mandatory.

The natural history of the disorder is important to know. That is, what would the malady do if left untreated? Certain painful spinal disorders can be self-limiting. That is, symptoms would disappear if left alone. If the symptoms were self-limiting and a practitioner still treated the pain, the pain would disappear. Was it the treatment or just the passing of time that caused the success? Voltaire stated: The purpose of the doctor is to entertain the patient while nature affects the cure. In this case, the entertainment would be expensive, and the physician may get credit when none is due.

A good example is muscle overuse syndrome or muscle strain. With muscle group strain, the relationship between the actin and myocin proteins that induce muscle contraction become disassociated. The result is muscle soreness that lasts 2-3 days and will resolve without treatment. Of course, a good massage will reduce symptoms and may limit the period of soreness, but will not change the ultimate outcome. Medications will also reduce symptoms but won’t change the eventual result. Developing the diagnosis will lead to the appropriate therapy. There may not be a pressing need for treatment except for symptom reduction.

However, if the muscle soreness is from overload of the muscles secondary to protection of an unstable spinal structure, the symptoms may not recede. Treatment of the muscle spasm will give temporary relief, but therapy will be ongoing like Sisyphus rolling the boulder up the hill. The diagnosis and treatment of the biomechanical fault is necessary to avoid the constantly overloaded muscles.

There are pains generated by the lower back that are significant and sometimes severe, but most of the time, low back pain is not dangerous. Many patients are fearful of paralysis and equate severe lower back pain with the eventual use of a wheelchair. For the vast majority of back pain patients, this is simply not true. The proper diagnosis provides peace of mind and relieves anguish.

A spine expert should take the time to help the patient understand the disorder, the natural history, and how treatment can help alleviate the problem. Most back problems need to be managed, not cured, and an understanding of the mechanics and physiology helps to reduce concerns and allow patients to reorganize their life.

2

Terminology

Many common terms for lower back problems are infamously inaccurate. Descriptions date back to the 1940s, a notorious time that is characterized by lack of spinal knowledge. Some of these ancient terms for some reason are still around today. To know the correct terms means you can have a better understanding of the disorder and remove some of the stereotypes.

Lumbago simply means low back pain. It does not describe any particular problem. This is not a good term to use for a diagnosis.

A strain is simply an injury to a muscle or tendon. Strains are very common but are typically self-limiting (they heal quickly without treatment). A back strain should last 1-12 days. If it lasts longer, it may not be a strain. The cause is overload to the muscles of the lower back.

A sprain is an injury to a ligament or a joint capsule. There are some ligaments in the spine that can be injured, but these are rarely a significant cause of pain. The sacroiliac joint is full of ligaments and can be injured, but this is also uncommon. Portions of the disc are made out of collagen as are ligaments, but a disc tear is very different than a sprain. You could use the sprain term loosely for a disc tear, but it is poorly descriptive. A sprain is not a good term to use for the back.

The most common pain in the back is from an annular tear. This is the prototypical cause of acute lower-back pain. Either the tear is preexisting and simply aggravated, or a new tear has formed. This is normally what a sprain really is. This will be explained in great detail later in the book.

A slipped disc is not an accurate term. Discs can’t slip as they are tightly attached to the vertebral bodies. Vertebral bodies can slip on each other, but this is a very different problem called a spondylolisthesis and will be discussed elsewhere in this book. If the vertebral body slips rearward, it is called a retrolisthesis.

A torn disc is synonymous with a degenerative disc or an annular tear and not a good description of the problem.

A bulging disc is also a poor term. It can mean a weakness and an out-pouching of the back wall of the disc or can mean an actual herniation. Again this is a non-descriptive term.

Sciatica is a term for nerve pain down the back of the leg from the sciatic nerve but is commonly used for any type of leg pain. Buttocks pain is normally sciatic pain. This is caused by compression of the L4, L5 and S1 roots, not by L1-L3 roots.

A herniated disc means that the back wall of the disc is torn through and through, and a portion of the nucleus (the jelly) is protruding through. This can cause pressure on the nerve root and resultant radiculopathy.

An extruded disc herniation means that the nucleus is now protruding through the PLL or posterior longitudinal ligament, the last structure to prevent it from actually touching the nerve.

A sequestered disc herniation means that the jelly (nucleus) has pushed through the PLL and is now a free fragment in the canal, no longer connected to the disc it came from.

Arthritis is a very poor term for the spine. This term is more appropriate for a peripheral joint, such as a knee or hip, where there is wearing of cartilage. The spine is genetically programmed in many people to develop disc disease, and arthritis is not a good term for these individuals.

Degenerative disc disease is the term to define the entire degenerative cascade of the disc. It is a poor term by itself. It is popular (and I even use it) because the initials, DDD, are so easy to use. It is, however, not truly a disease, but a process due to genetics, injury, and occupation. Individuals with DDD may or may not have symptoms. It should be called DDS, or degenerative disc syndrome, but I would spend all my time with my dentist trying to explain the difference between his back pain and his profession.

IDR or isolated disc resorption is an advanced form of DDD, where the disc has fully reabsorbed or worn away and the vertebral bodies are essentially sitting on top of each other, bone on bone. This situation creates its own set of peculiar symptoms but still may be asymptomatic in many individuals.

Scoliosis is a curvature of the spine in the frontal plane (coronal plane) using the Cobb method (see chapter 10), greater than ten degrees. If it is less than ten degrees, it’s not a scoliosis.

Kyphosis is the curve noted on the side or sagittal view. The term, by itself, does not indicate pathology, but just describes the type of the curve. It is normal for the thoracic spine to have some kyphosis. An increased or decreased curve may note pathology.

Lordosis is the mirror image curve to the kyphosis. It normally is found in the neck and lower back. Again, it is normal, and it does not indicate pathology unless increased or decreased beyond a certain point.

Cramping is a condition of muscle spasm. Many times, leg cramping has nothing to do with the lumbar spine; but if there is nerve compression, the muscle involved may more easily cramp. This needs to be differentiated from vascular and neurological diseases, which also can causes cramping. Most leg cramping, however, is not significantly pathological.

Dystonia is an abnormal prolonged cramping of the muscle normally not caused by injury to the peripheral nervous system or muscle. This condition is noted by continuous contraction.

The nerve root is the structure where the individual sensory and motor nerves of the cauda equina join in the area near the exit foramen. It is different in that the dorsal root ganglion is part of it and has less resistance to stretch and compression. The DRG is the origin of the cell bodies of the sensory nerves and is more sensitive to compression and irritation.

The peripheral nerve is the continuation of the nerve root. It does not contain cell bodies and has a tougher coating and packing (epineurium and perineurium), making it more resistant to compression.

The central nervous system is obviously the control mechanism for the body. Its cells are less resistant to compression and injury but are protected by bony vaults (the skull and spine).

Peripheral neuropathy is a condition where the actual nerve itself becomes diseased and sends aberrant signals to the brain (process normally starts in the legs).

Radiculopathy is inflammation of a single nerve root in the spinal canal normally from compression from a herniated disc. This condition can also occur from a stretched or chemically irritated nerve root.

Far Lateral Herniation is a disc herniation on the outside of the spinal canal in the far lateral position. A disc herniation anterior to this position will not cause any nerve compression and will be generally painless. There are occasions that a herniation in this position can be missed on an MRI by a radiologist.

Cauda equina syndrome is an emergent condition where severe compression of the nerves that exist in the lower back occurs. Normally caused by a herniation, the compression is global, and the bowel and bladder nerves are also affected. Symptoms are normally classic and urgent treatment is normally needed.

3

The History of the Sources of Back and Leg Pain: Pain Generators

The biggest question for years regarding the lower back was the origination of the pain source. This issue had dogged physicians, chiropractors, and therapists for years. Theories had abounded regarding why the spine was painful. Some blamed our two-legged stance for all our woes. Others implicated bad posture. Our understanding of these pain generators has evolved in just over the last fifty years. It is interesting to look at some of the past history and controversy regarding spine diagnosis and treatment. The old saying is true: You can’t know where you’re going if you don’t know where you’ve been.

Only since the discovery of Roentgen rays (X-rays) in 1895 have we developed a reasonable understanding of the disorders of the lower back. This new X-ray technology spread like wildfire. Literally within twelve months of its discovery, X-rays were being used for human diagnosis and not just in Germany but all over the world. X-rays were a substantial advance. Certainly, before this amazing invention, anatomists knew what the spine and its supporting structures looked like through cadaver dissection; but physicians really didn’t know how aging and degenerative disorders manifested in the spinal column in a living subject. With X-rays, one could actually see the changes to the bone with the effects of aging or trauma in living subjects. Unfortunately, even with this advance, X-rays could visualize only bony structures. The nerves and discs of the spine continued to remain an obscurity at that time.

Disc problems were initially not understood. Why individuals repeatedly presented to doctors with severe leg pain and weakness was a mystery. An early physician, Dr. Walter Dandy of Johns Hopkins, theorized that there was some structure compressing the spinal nerves and—flouting conventional wisdom—surgically opened up the spinal canal in a patient. He found a mass in the canal compressing the nerves. Removal of this substance relieved the leg pain. Through Dr. Dandy, medical science finally found one of the first defining causes of leg pain. You would think this finding would be one of the eureka moments of medicine; however, this intra-canal material was mistakenly thought to be a tumor instead of what its tissue origin really was.

Drs. Mixter and Barr were the first to discover that this substance was actually material originating from the inside of the disc (what we now know as a herniated nucleus pulposis). This was a huge breakthrough. Only with this evidence did the understanding of degenerative spinal disorders take a great leap forward.

Finally, we had developed a reasonable understanding for some of the causes of leg pain. The sources of lower-back pain, however, took many more years to be discovered. A very interesting study by Drs. Smith and Wright in back in the 1960s in England was one of the first to advance our knowledge. They performed back surgery to remove a herniated disc and then, during surgery, tied multiple sutures to various anatomic structures. These tagged sutures were left long enough to protrude out of the incision after wound closure. When the patients awoke from anesthesia, the physicians would gently tug on these sutures and record the symptoms noted before the sutures were clipped off below the skin. Muscle, tendon, and ligament would generally not cause pain. Tension on the nerve would cause leg pain but not back pain, and tension on the back of the disc would cause back pain.

Dr. Kuslich from Minnesota expanded on this study. He performed surgery on patients with herniated discs with local anesthesia and sedation only. In other words, he did not put the patients to sleep but numbed the local structures similar to what a dentist does. The patients were awake enough to be able to describe sensations as the operation progressed.

Dr. Kuslich would first stimulate the skin and record the patient’s reaction to this stimulus. He then would use a local numbing agent (similar to Novocain) to numb the skin, incise it, and dissect down to the fascia (the next structure immediately under the skin.) Again, he would stimulate the fascia, record the patient’s reaction, anesthetize this structure, incise it, and dissect down to the next structure.

He continued to dissect down layer by layer with stimulation. This brought him through the ligaments, muscle, bone, ligamentum flavum, capsule, and finally nerve and disc. His findings were extremely interesting.

Patients with low back pain almost never had significant reproduction of this pain when stimulating muscle or ligament. Only rarely would a facet joint cause typical low back pain. A normal (non-compressed or non-inflamed) nerve never caused leg pain upon stimulation. It would only give a feeling of numbness or pins and needles. An inflamed nerve (from a herniated disc) would cause exact reproduction of leg pain. Presuming the patient also had lower back pain, when the back of the disc (annulus) was stimulated, this would cause exact reproduction of their lower-back pain. If the disc and nerve were stimulated at the same time, it would cause buttocks or sacroiliac pain.

Based upon these as well as many other studies, we now understand that most of the time, lower-back pain originates from the disc. The facet joints, vertebral bodies, and spinal nerves can also be pain generators for lower-back pain. Buttocks and leg pain primarily is generated from the nerve roots.

Now that we know where the sources of lower back and leg pain come from, we can use this information to make a more complete diagnosis. In addition, we can target each source to give much higher quality relief and solutions to pain in the spine and legs.

4

The Anatomy and Function of the

Lumbar Spine

The spine is really quite amazing in its construction. It has evolved over eons to the foundation that supports us today. We take our spinal column for granted until we develop pain and dysfunction.

The purpose of the spine seems self-evident but deserves repeating. The spine supports the body. It allows enough motion to position the head and arms for the activities of daily living. The spine holds the viscera in place to function and—with the ribs—creates a cavity for the lungs so they don’t collapse. The spine also protects the spinal cord from compression and injury. The spinal column, through its discs and facets, has to have shock-absorbing capability so impact doesn’t injure the vertebra. The spine also has to be resistant to too much motion to prevent actions that would damage the spinal cord and nerves.

Many people have made the argument that our unique ability to walk upright is the direct cause of our back problems.