Diagnosing Back Pain

One general session that will be given at Back Talk, Indiana Spine Group’s continuing medical education symposium, is entitled Making the Diagnosis| Differential Factors in Spinal Diagnosis. This presentation will be given by neurosurgical spine surgeon Kenneth Renkens, MD, FACS.

During this presentation, Dr. Kenneth Renkens will discuss the differential diagnoses of lower back and extremity pain. The importance of identifying coexisting conditions affecting spinal pain and treatment will be reviewed. Additionally, Dr. Renkens will discuss spinal infections and inflammations that present as back pain neck pain.  

·         Understand the clinical algorithms to effectively diagnose and treat patients that present with back or neck pain. 

·         Discuss comprehensive evidence-based treatment options for the spine patient, from a non-operative and operative treatment prospective; including indications, applications and expected outcomes.

·         Identify common and uncommon spinal disorders; including spinal trauma, and discuss the symptoms, diagnosis and treatment options. 

·         Address conditions and prevalent diagnoses that affect patients at specific life-stages.  Additionally, discuss intrinsic and extrinsic factors affecting these diagnoses, as well as prevention, diagnosis and treatment of these spinal disorders.

·         Highlight new and emerging technologies for the treatment of spinal disorders and abnormalities; including the indications and potential benefits. 

Indiana Spine Group has three minimally invasive spine specialists treating patients with back and neck pain.  The goal of minimally invasive spine specialists is to diagnose the cause of a patient’s neck / back pain – and to treat this cause. Many times medical management and/or minimally invasive spine treatments can effectively eliminate a patient’s neck or back pain.

To learn more about our minimally invasive spine specialists, Kevin Macadaeg, MD, Jonathan Gentile, MD, and John Arbuckle, MD, visit their biographies. Additionally, their videos provide insight into their treatment philosophy and expertise. 

For more information about Indiana Spine Group or to schedule an appointment call:  (317) 228-7000 or toll-free (866) 947-7463.

One of the videos on the updated educational resource section of Indiana Spine Group’s web site is about back pain. In this video, minimally interventional spine  specialist John Arbuckle, MD, defines spinal/back pain, and he provides an overview of diagnosing back pain and treatment. To view this spine wellness education video on spinal / back pain, click here. 

Another sponsor for Back Talk, Indiana Spine Group's continuing medical education symposium is Stryker Interventional Spine.  Stryker Interventional Spine specializes in minimally invasive spine treatment options for the relief of chronic back pain. Stryker Interventional Spine provides physicians with a wide range of minimally invasive spine surgical tools. This includes spine surgical tools for   radiofrequency, vertebroplasty, disc decompression and discography. 

Vertebroplasty is a minimally invasive spine procedure that is used to treat vertebral compression fractures (VCFs) as a result of osteoporosis, trauma or tumors.  

Discography is a procedure that is used to diagnose the the cause of back pain; and to identify which spinal disc(s) are involved.

Radiofrequency is a type of injection which utilizes an injection which involves heat – and the goal of this interventional pain management procedure is to interrupt pain signals therefore eliminating back pain. 

Disc Decompression is a spine surgical procedure that is performed to alleviate pinched nerves. The two common types of decompression spine surgical procedures are microdiscectomy and laminectomy.  

To learn more about Stryker Interventional Spine, and their minimally invasive spine products visit their web site.  

Another talk scheduled for Back Talk, Indiana Spine Group's continuing medical education program is entitled, Spinal Disorders | Uncommon & Difficult. Many times, these patients present with back pain and other symptoms that are similar to many spinal diagnoses, therefore these uncommon problems can be difficult to diagnose.

In one talk, Dr. Michael Stack will discuss benign spinal disorders. This will include a review of rheumatologic and endocrinologic disorders as well as the symptoms, diagnoses and treatment indications. Dr. Stack is a rheumatologist with Diagnostic Rheumatology & Research PC.

Dr. Kenneth Renkens, a neurosurgical spine surgeon with Indiana Spine Group, will discuss the urgent spinal diagnoses. During his discussion, he will identify the red flags of spinal and nonspinal conditions that can present as back pain. This includes infections and vascular disorders. Additionally, he will review the symptoms and diagnostic indications of primary and metastatic spinal cancer. 

During this talk, Dr. Macadeg will discuss the normal spine, and the normal degenerative cascading process of the spine. He will discuss evidence-based guidelines for diagnosing neck and back pain and review recommended spinal diagnostic testing. This review will also include identification of red flags that present as back pain. Additionally, Dr. Macadaeg will discuss the different minimally invasive diagnostic tests and their indications. This discussion will include selective nerve root injects, facet joint injections and discograms. 

One test for diagnosing back pain for patients suffering from chronic lower back pain (lumbar spine) is a discogram. The objective of this diagnostic test is to determine if a suspected disc, or discs, is/are a potential source to a patient’s lower back pain.

To perform this spinal diagnostic test, the patient is given medicine intravenously for mild sedation. Using an X-ray machine called a fluoroscope, a needle is placed into the spinal disc(s) that are suspected to be causing low back pain, as well as an unsuspecting adjacent disc to serve as a ‘control.’ A dye is then injected into the disc(s) of which creates pressure in the disc and outlines its internal structure. 

In a normal disc, the patient typically experiences a slight pressure sensation in the back, and the X-ray image of the disc typically appears intact. If a disc is a source to a patient’s low back pain, the patient should experience pain similar in character and location of their usual low back pain. The X-ray image of a painful characteristically demonstrates a tear extending from the inner ‘nucleus’ through the outer ‘anulus.’

Ankylosing Spondylitis is defined as a chronic inflammatory disease which primarily affects the sacroiliac joints, spine and hip joints. (The sacroiliac joints are the joints where the spine attaches to the pelvis.)  With ankylosing spondylitis the inflammation of these joints can lead to the bony fusion of the joints.  A bony fusion is where the fibrous ligament transforms to bone – then these joints permanently grow or fuse together. 

Ankylosing spondylitis is more common in young adult men, and once developed lasts their lifetime.  The cause of ankylosing spondylitis is unknown but studies have shown a strong link with a specific genetic marker.  In blood tests of individuals diagnosed with ankylosing spondylitis 90 percent of them had the genetic marker HLA-B27.

One of the most common and first symptoms of ankylosing spondylitis is lower back pain and stiffness.  And unlike lower back pain caused by over-exertion or another type of injury that will subside with rest, with ankylosing spondylitis the lower back pain may get worse after rest.  Another common symptom of ankylosing spondylitis, is sacroilitis.  This is where there is inflammation of the sacroiliac joint, the joint that connects the spine to the pelvis, and this inflammation results in pain in the buttocks that may radiate down the thighs, but not below the knees.   

Once diagnosed, at this time, there is no treatment to prevent the progression of ankylosing spondylitis.  Treatment focuses on minimizing the symptoms of lower back pain, and may include exercise/physical therapy and medications. 

Diagnosis

In males, osteoporosis is often times is undiagnosed and overlooked.  That is why it is important to let your physician know if you notice a change in posture, loss of height or sudden back pain.  To diagnose osteoporosis, your physician will order a DEXA screening – which is a specialized X-ray that measures your bone mass.  Additionally, your physician will conduct a complete medical exam to identify risk factors; i.e. medial history, physical exam, urine and blood tests.

Prevention

Some risk factors for osteoporosis are unavoidable, but the good news is many can be controlled.  The following identifies a few key recommendations to help prevent and treat osteoporosis:

1. Maintain a healthy lifestyle; no smoking, exercise, a nutritional  diet and minimal alcohol use.

2. Exercise!  Weight-bearing exercise is important.  Weight-bearing  exercises are those activities where bone and muscles work against  gravity.  Popular weight-bearing exercises include walking, jogging and tennis/racquet ball.  Also weight lifting is good.  Be sure to talk to your physician before starting an exercise program.

3. Regular check-ups.  Routine medical examinations help your physician  to identify any underlying medical conditions that can affect bone  health.

4. Adequate levels of calcium and Vitamin D.  The National Osteoporosis Foundation recommends that men under 50 years of age get 1,000 mg of  calcium daily, and for over 50 years old 1,200 mgs.  Additionally, it is   recommended that men under 50 get 800-1,000 IU of vitamin D3 per day  and over 50 years of age, 800 – 1,000 IU.  Note:  Vitamin D3 is an active form of vitamin D. 

One type of arthritis that affects the spine/back is rheumatoid arthritis.  This common type of arthritis is an autoimmune disease that causes chronic inflammation of the tissue around the joints and other organs.  One of the most debilitating types of arthritis, according to the Arthritis Foundation, rheumatoid arthritis affects approximately 1.3 million Americans.  This disease is more common in females, than males; there are 2.5 times more women with rheumatoid arthritis than men.

When rheumatoid arthritis affects the spine, generally it is the cervical spine (neck).  Rheumatoid arthritis rarely affects the lumbar (lower back) or thoracic (chest area) spine.A few symptoms of this rheumatoid arthritis affecting the spine may include headache, neck pain or stiffness or weakness in the arms and legs.  Once rheumatoid arthritis is diagnosed, if there are symptoms that indicate the cervical spine is affected, an X-ray of the cervical spine will be taken.  This X-ray can be used to assess the joints and intervertebral disc spacing and the overall structure.  Additionally, a MRI or CT Scan may be performed to evaluate if there is any spinal cord compression.

Diagnosing vertebral compression fractures can be difficult – in that X-rays do not always show the fracture.  In this instance, if the patient has back pain and an X-ray does not show a fracture – many times it is assumed that the back pain is caused by muscle strain.

That is why sometimes, it is important to see a spine specialist; i.e. a minimally invasive spine specialist that focuses on spine diagnosis and treatment.  One key component in diagnosing spinal fractures is the patient’s medical history.  Additionally, a clinical exam is important to determine the sensitivity and tenderness around the affected vertebrae. 

If a vertebral compression fracture is suspected, even if an X-ray does not show a fracture – other diagnostic tests may be ordered as a result of the patient’s medical history and clinical exam.  These tests can include a CAT scan, MRI or nuclear bone scan. 

If a vertebral compression fracture is diagnosed – it is important to determine the cause for effective treatment.  The most common cause of a vertebral compression fracture is osteoporosis but other causes are trauma or some types of cancer. 

If the cause of the vertebral compression fracture is determined to be osteoporosis, common treatment options include bracing, analgesics, medications to help sustain or restore bone mass, and vertebral augmentation. In vertebral augmentation, the goals of treatment are to stabilize and eliminate the pain caused by the vertebral compression fracture.  The two types of vertebral augmentation available include vertebroplasty and kyphoplasty. 

One of the most common causes of spine fractures – referred to as vertebral compression fractures, is osteoporosis.  One statistic projects that there are approximately 750,000 spine fractures resulting from osteoporosis per year in the U.S.

Many times, spine fractures resulting from osteoporosis are overlooked and not diagnosed.  Frequently, when older people complain of back pain – it is thought to be related to muscle strains or normal aches and pains due to aging.  It is important for individuals to recognize that if they have sudden acute back pain – following an activity such as golf (or other twisting), lifting or even a small fall – this could be the result of a fractured vertebra.  Following the acute pain resulting from the fracture – the pain may then lead to chronic back pain and therefore many times is thought of as just that – back pain.

When you think about osteoporosis and vertebral compression fractures – this does not just occur in the elderly.  Anyone who is 40 or over is susceptible to this – depending on their risk factors for osteoporosis.

If you suspect that your back pain is a result of a vertebral compression fracture, see your physician or a minimally invasive spine specialist.  For more information, call our office at 317.228.7000. 

This blog entry will answer some common questions asked about vertebral compression fractures.

What exactly is a vertebral compression fracture? 
A vertebral compression fracture is where a bone or bones in the spine fracture/break. 

What causes a vertebral compression fracture? 
A vertebral compression fracture can be caused by severe trauma.  For example an automobile accident or a fall from extreme height.  In older individuals the most common cause is if from osteoporosis.  Additionally, cancer can also precipitate a vertebral compression fracture.  Generally, a vertebral compression fracture is of the lower, back (lumbar spine).

Are vertebral compression fractures common?
It is estimated that osteoporosis will result in approximately 1.5 fractures annually.  Although you hear more about hip fractures, the most common fracture as a result of osteoporosis is a vertebral fracture.  It is estimated that more than half of the fractures as a result of osteoporosis are vertebral compression fractures, over 700k annually.

What are the symptoms of a vertebral compression fracture? 
The most common symptom is sudden onset back pain that becomes persistent. If the vertebral compression fracture is the result of osteoporosis, this fracture and accompanying pain can be caused by normal activities and not the result of trauma; i.e. a fall. Other symptoms include back pain that is more severe when  standing or walking, limited spinal mobility and height loss or a forward stooped posture (Dowager’s hump). 

How are vertebral compression fractures diagnosed? 
Vertebral compression fractures are diagnosed with an X-ray.  If there is a spinal fracture on the X-ray, the physician may order a CT-scan to determine the extent of the fracture or an MRI – depending upon the patient’s symptoms. 

One of the main reasons people go to their doctor is for back pain!  This session, will provide physicians and health care practitioners the necessary tools to treat their patients with acute low back pain.  The presenter of this session is James Anderson, MD.  Dr. Anderson is a family practice physician with Anderson Family Practice located in Greenfield, Indiana.

At this session, Dr. Anderson will provide an overview of the initial assessment and neurological exam.  He will discuss the differential diagnoses for acute low-back pain, including red flags.  Additionally, initial management and patient education of patients with back pain will be reviewed. 

For individuals diagnosed with a contained herniated disc or protruding disc, which are suffering from leg or lower back pain - one newer treatment option for pain relief is nucleoplasty. 

Nucleoplasty provides a minimally invasive spine treatment alternative.  With this minimally invasive spine procedure, radio waves which produce energy are used to dissolve (ablate) the unwanted disc tissue, and this relieves the pressure causing the lower back pain or leg pain.

This procedure is performed by a physician who is a minimally invasive spine specialist.  During this spine procedure, which takes less than an hour, the patient is awake and the physician will use a local anesthetic.  Guided by fluoroscopy (internal X-ray), the physician will insert a catheter-like device to the affected spinal disc. This catheter will deliver small amounts of radio wave energy to the damaged disc that will create a molecular reaction that will result in the spongy tissue in the damaged disc to dissolve.  This will reduce the pressure in the damaged disc, and thereby allow the herniation in the disc to retract.  The goal of nuceloplasty, is to reduce the pressure on the affected nerve and therefore eliminate back pain.

One of the tools that we use to diagnose back pain is selective nerve injections (SNI).  Imaging studies, such as MRI’s, do not always show which nerve is causing the back pain, and selective nerve injections are effective in helping us to isolate the source of the patient’s pain. 

With diagnostic selective nerve injection, just enough medication is used to numb one or two spinal nerves.  This medication is then injected, and this helps us to determine if the nerve root is causing the pain. 

Additionally, a study that I co-investigated concluded that selective nerve injections were also a valuable tool for patients requiring surgery for radiculopathy; a lumbar cervical decompression.  This study determined that selective nerve injections can accurately determine the presence of a specific painful nerve root in cases where physical exam and/or MRI findings are equivocal.  This helps spine surgeons determine their surgical treatment and oftentimes limiting its scope.  Here is a link to the research study. 

A minimally invasive spine specialist is a physician that specializes in the treatment of patients with spine disorders.  The focus of their patient care is to diagnose the cause of the spine problem, and then to treat the specific cause of the problem which will usually alleviate the symptoms; i.e. back pain.

A physician who is a minimally invasive spine specialist is usually board-certified in anesthesia as well as pain management.  Other terms used for this specialty include pain management, interventional spine specialist or minimally interventional spine specialist.  Regardless of the term used, key is physician’s board certification.

On Friday (August 22), there will be an in-depth review of spinal diagnostics.  One session entitled, The Essentials of Diagnosing   Spinal Pain will be presented by Kevin Macadaeg, MD.  Dr. Macadaeg is a minimally invasive interventional spine specialist with Indiana Spine Group.  
 

Neck and back pain are common symptoms of many underlying spinal problems.  Key to diagnosing the cause of this pain is to have an understanding of the overall spinal mechanics and also what is “normal”, in respect to degenerative changes of the spine.

The objectives of this presentation include:

§         Define the normal aging process and common degenerative changes of the spine.

§         Identify common spinal problems that cause lower back and neck pain and key indicators for diagnosis. 

§         Review the evidence-based guidelines for the diagnostic triage of lower back pain, including appropriateness and use of invasive diagnostic testing.

§         Identify the “yellow” and “red” flags that present as back pain.