Compression Fracture

• Cause/Pathophysiology

  • Generally thoracic and lumbar spine injuries

  • Relatively low energy axial or flexion trauma and/or related to bone insufficiency (osteoporosis)

• History and symptoms

  • Trauma - frequently a fall onto backside

  • Gradually worsening pain with insufficiency fractures

• Exam Findings

  • TTP over affected vertebrae

  • Thoracic anterior compression fractures lead to kyphosis 

  • Pain with ROM

• Imaging

  • X-Ray - AP and lateral​

    • difficult to determine acuity​

  • CT​

    • helps to diagnosis amount of compression and any displacement ​

  • MRI

    • helpful in determining acuity in the absence of known onset​

• Treatment:

  • Conservative - most cases

    • manage pain​

    • +/- brace/TLSO

    • walker if needed

  • Cement kyphoplasty 

    • fractures l​ess than 3 months old, significant pain, significant vertebral height loss​

  • Treat osteoporosis 

• Common ICD 10​ code

  • S32.000A - lumbar

  • S22.000A - thoracic

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Degenerative Disk Disease/Spondylosis

• Cause/Pathophysiology

  • Age-related degeneration and flattening of the cervical/thoracic/lumbar intervertebral disk​

  • May be associated with vertebral spurring and/or thickening of the ligament flavum 

  • C5-6, C6-7 most common level for C-Spine

  • L4-5, L5-S1 most common level for L-Spine

• History and symptoms

  • Cervical​

    • neck pain, upper shoulder/back pain​

    • worsens with movement

    • may affect sleep

    • +/- radicular symptoms in arms

  • Lumbar​

    • back pain, buttock pain, +/- posterior thigh pain​

    • may worsen with activity or motion

    • +/- radicular symptoms in legs

• Exam Findings

  • +/- TTP at affected level spinous process​

  • +/- TTP paraspinal muscles

  • Decreased ROM

  • +/- myelopathy, radiculopathy, or sensory abnormalities 

• Imaging

  • X-Ray - minimum AP and lateral

    • Evaluate for disk space, spurring, listless​​​

  • MRI - if conservative treatment fails to improve symptoms or neurologic deficits

• Treatment:

  • Conservative​

    • NSAIDs​

    • PT

    • Cortisone Injection (ESI, nerve root or facet)

  • Surgery referral for neurologic deficits

• Common ICD 10 codes​

  • M50.30 - Cervical DDD

  • M51.36 - Lumbar​ DDD

  • M54.2 - cervicalgia/neck pain

  • M54.5 - Low back pain

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Herniated Nucleus Pulposus (HNP)

• Cause/Pathophysiology

  • Extrusion of the nucleus pulposus into or through the annulus fibrosis into the spinal canal​ causing compression or chemical irritation to the corresponding level nerve root

  • Can happen in cervical (most common C5/6, C6/7), thoracic, or lumbar (most common L4/5, L5/S1) spine

  • Sciatica is another term frequently used for leg pain caused by lumbar HNP 

• History and symptoms

  • Can be acute or gradual onset​

  • Can be uni or bilateral arm/leg pain, numbness, tingling, with or without neck/back pain​

    • location of symptoms depends on the level involved (dermatomes, myotomes)​

  • Symptoms may worsen with sneezing, coughing, straining

  • May positionally worsen

  • RED FLAG SYMPTOMS OF CAUDA EQUINA REQUIRING EMERGENT SURGICAL REFERRAL: URINARY RETENTION, BOWEL INCONTINENCE, SADDLE PARASTHESIA, SEVERE ISOLATED MYOTOMAL WEAKNESS, DTR DEFICIT

• Exam Findings

  • Cervical​

    • Decreased ROM​

    • ROM may cause radicular symptoms

    • +/- TTP at affected level of spine

    • Spurling's maneuver

    • +/- neurologic deficits

  • Lumbar

    • Decreased ROM​

    • ROM may cause radicular symptoms

    • +/- TTP at affected level of spine

    • Frequently TTP sciatic notch

    • Straight leg raise, Flip test

    • +/- neurologic deficits

• Imaging

  • X-Ray - AP, lateral minimum

    • ​Will not show HNP, but may show age related degenerative changes that may predispose a person to HNP​​​

  • MRI

    • Primarily and emergently if any concern for caudal equina, significant neurologic deficit, or intractable pain​

    • If conservative treatment fails, to determine whether or not there is surgical pathology

• Treatment:

  • Conservative - ~90% improve without surgery

    • Steroid taper or NSAIDs​

      • my personal preference for acute moderate to severe symptoms is 12 day taper, if no contraindications​

    • +/- short course of opioid or muscle relaxer (if used, use for as short as possible)

    • Relative rest

    • PT

    • Educate regarding lifting, posture, red flag symptoms

  • Surgery - only ~10% will require

• Common ICD 10 codes​

  • M50.90 - cervical unspecified​

  • M50.00 - cervical with myelopathy

  • M50.10 - cervical with radiculopathy

  • M51.86 - lumbar

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Scoliosis

• Cause/Pathophysiology

  • Abnormal lateral curvature of the thoracic and/or lumbar spine >10°

  • Adult onset degenerative - develops due to DDD and/or spondylolythesis​

  • Pediatric - usually idiopathic 

• History and symptoms

  • Usually asymptomatic

  • Usually present because associated deformity is noted​

    • uneven shoulder​ height

    • rib hump

    • spinous process curvature

    • excessive kyphosis or lordosis

  • Degenerative scoliosis may have pain due to the degenerative changes

• Exam Findings

  • Same as above​

  • Degenerative adult scoliosis may have symptoms of DDD or spondylolysthesis

• Imaging

  • X-Ray - AP and lateral full length spine films

    • evaluate amount of curvature (Cobb ​​​angle)

  • MRI - 

    • Generally not indicated in pediatric​

    • May be helpful in adults if neurologic involvement, significant pain, or failure of conservative treatment to evaluate for stenosis 

• Treatment

  • Pediatric - monitor for worsening curvature​

    • bracing for curvature >20°​

    • Surgery for >50°

  • Adult - treated similarly to DDD

    • NSAIDs​

    • PT

    • Surgery for significant neurologic symptoms or respiratory involvement

• Common ICD 10 codes​​

  • M41.20 ​

  • M41.9

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Spinal Stenosis (Cervical and Lumbar)

• Cause/Pathophysiology

  • Usually, degenerative narrowing of the spinal canal that will result in nerve root compression ​​

• History and symptoms

  • Usually over 60​

  • Cervical​, upper back, +/- upper extremity radicular symptoms

    • radicular symptoms vary depending on level of stenosis​

  • Lumbar, buttock, posterior thigh, +/- lower leg/foot radicular symptoms

    • ​radicular symptoms vary depending on level of stenosis​

    • Neurogenic claudication - pain worsens with walking and/or standing, progresses from proximal to distal

    • May note pain improves when leaning forward

• Exam Findings

  • May be benign or subtle​

  • +/- weakness

  • +/- sensory deficit

  • +/- DTR abnormalities

• Imaging

  • X-Rays - AP and lateral, obliques may help evaluate for foraminal narrowing

    • evaluate for vertebral alignment/spondylolisthesis​​​

  • MRI - if significant neurologic deficit, symptoms do not improve with conservative management to evaluate amount of stenosis and nerve compression

• Treatment

  • Conservative options

    • NSAIDs if no contraindication​

    • PT

    • ESI

  • Surgeon referral - unacceptable symptoms that fail conservative treatment or neurologic deficits

• Common ICD 10 codes​

  • M48.02 - cervical​

  • M48.061 - lumbar without neurogenic claudication

  • M48.062 - lumbar with neurogenic claudication

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Sprain/Strain

• Cause/Pathophysiology

  • Spinal muscle and/or ligamentous injury involving a stretching or contraction mechanism​

  • Whiplash injury is a classic mechanism in the neck

  • Can be stable or unstable

  • +/- trauma

• History and symptoms

  • +/- mechanism​

  • Neck or back pain

  • Worse with motion​

  • +/- muscle spasm

  • +/- headaches with cervical strain

• Exam Findings

  • Decreased ROM​

  • TTP of paraspinal muscles

  • NO neurologic findings

• Imaging

  • X-Rays - evaluate for fracture, vertebral alignment​

    • AP, lateral, oblique, odontoid views in the setting of trauma,

    • AP and lateral with no trauma​​

    • AP, lateral, flexion/extension views if chronic

  • MRI

    • Can be helpful in evaluation if abnormal X-Ray findings or symptoms fail to resolve after appropriate conservative treatment​

• Treatment

  • Conservative

    • NSAIDs​

    • Muscle relaxers if spasm

    • PT

    • Ice/heat modalities

    • If symptoms are severe, a short course of opioids 

    • Short period of use with lumbar support or soft collar, if necessary (Personally, rarely use)

  • Surgery

    • Unstable injuries

• Common ICD 10 codes​​

  • S13.4XXA - cervical ligament sprain

  • S13.8XXA - cervical muscle strain

  • S39.012A - lumbar strain

  • S33.5XXA - lumbar sprain

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Lumbar Spondylolisthesis

• Cause/Pathophysiology

  • Vertebral body anterior translation related to chronic degenerative changes (Degenerative spondylolysthesis) or stress fracture of the pars (Isthmic spondylolysthesis)​

  • Isthmic can be seen in younger populations involved in activities that involve repetitive spinal extension (football linemen, gymnastics, diving) 

  • Can lead to canal stenosis

• History and symptoms

  • Complain of back pain​

  • Worsened with activity​

  • +/- buttock or posterior thigh pain

• Exam Findings

  • Loss of lumbar lordosis (flat back)​

  • +/- spinous process step-off

  • May have hamstring tightness

• Imaging

  • X-Ray - AP, lateral, oblique

    • evaluate for vertebral alignment/anterior slippage

    • evaluate for pars fracture on oblique images - neck of the "Scotty Dog"​​​

  • MRI - insetting of progressive symptoms, neurologic deficits

    • evaluate for associated stenosis 

• Treatment

  • Conservative

    • PT​

    • NSAIDs, if no contraindication

    • Support brace periodically for symptoms relief

  • Surgery referral for significant or worsening slippage, neurologic symptoms

• Common ICD 10 codes​

  •  M43.16​

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