Spine-3D-Model

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

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

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

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

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

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

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