Chronic lower back pain (Full Version)

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Alex Brenner PT MPT OCS -> Chronic lower back pain (August 8, 2005 9:53:00 PM)

31 year old female has a long history of low back pain. Pain mostly located centrally around L4-5 and L5-S1. No radicular pains but does get radiating symptoms into her left buttock. What are the findings?

[image]http://img.photobucket.com/albums/v85/brennerak/lowback1.jpg[/image]

[image]http://img.photobucket.com/albums/v85/brennerak/lowback2.jpg[/image]

[image]http://img.photobucket.com/albums/v85/brennerak/lowback3.jpg[/image]



Sebastian Asselbergs -> Re: Chronic lower back pain (August 9, 2005 2:05:00 AM)

that's a darn tooting odd looking fifth spinous process - is that an old fracture? Middle view. And the ilia look like they were part of that serious landing on her behind (just surmising of course - little screen and all...) - look like lateral to SI joints some fracture lines...



jma -> Re: Chronic lower back pain (August 9, 2005 8:14:00 AM)

Yes, there seems to be some old/recent fracture lines on the ilium, lateral to the SI. True, the last spinous process looks very odd,compared to the others. Don't know what that is all about.



chiroortho -> Re: Chronic lower back pain (August 9, 2005 9:55:00 AM)

Serious spondylolysis going on there (said in my best southern accent). No slippage but bilat pars defects.

See 'em frequently. Do the cuboid whip and all is well.



tr6454 -> Re: Chronic lower back pain (August 9, 2005 10:04:00 AM)

I agree.
The obliques will show it even better, but since this lateral shows it nicely the extra rads are not needed.



Shill -> Re: Chronic lower back pain (August 9, 2005 10:07:00 AM)

Greg,
Can you tell how old the pars defect is on this film? I have a current patient with one of these, without a prior film for comparison, and its not mentioned by the radiologist.
Thanks.

Others - I think the ilial fx lines are bowel. I might be wrong, as I often am.



ehanso -> Re: Chronic lower back pain (August 9, 2005 10:18:00 AM)

LOL on the whip Greg.
I agree with the spondylolysis. Poor gal probably lost her "scotty dog". I have had fair success using stabilization exercises so they can control the pain.



JLS_PT_OCS -> Re: Chronic lower back pain (August 9, 2005 10:24:00 AM)

Shill-
A bone scan is frequently used to determine if there is an acute process or if this is congenital. I could have sworn I read a really good case study in JOSPT explaining this sort of thing, and the use of manipulation in it's care...can't think of who wrote it...
:)
J



chiroortho -> Re: Chronic lower back pain (August 9, 2005 10:52:00 AM)

[QUOTE]Can you tell how old the pars defect is on this film?[/QUOTE]Not a chance. But if I wanted to impress her, I'd gamble and ask her if she did a lot of gymnastics as a kid. She'll say yes, and you'll be a genius.



gerry -> Re: Chronic lower back pain (August 9, 2005 12:06:00 PM)

As an aside, the normal curves seem decreased. Is this someone in the military used to standing at attention?



UTDC -> Re: Chronic lower back pain (August 9, 2005 4:09:00 PM)

Hello all,
1. She has an IUD
2. Bilateral pars defects as Greg noted. The only way this could be acute is if she had a mechanism of injury which would explain an acute fracture. For the most part, they are stress fractures that occur earlier in life- not congenital as once thought. Don't get fooled into thinking that this is causing her pain, as it may or may not be the case. Flexion/extension or hanging views could help rule out instability. A SPECT (vs a plain bone scan) helps to determine how old the lesion is. The only time this is really useful, is in the young teenager when you suspect a developing pars defect, if you can catch it before it fractures, you can sometimes reverse the process with a good LSO.
3. Probable bone island in the body of T9.
4. The L5 spinous does look a bit odd- but just a normal varient.

Jeff



jma -> Re: Chronic lower back pain (August 9, 2005 4:15:00 PM)

Kind of straight for the lumbar spine, don't you think?



UTDC -> Re: Chronic lower back pain (August 9, 2005 4:23:00 PM)

JMA,
This is probably a recumbent film, which would explain the lack of curves.



jma -> Re: Chronic lower back pain (August 9, 2005 4:28:00 PM)

What does the RD on the last image indicate?



UTDC -> Re: Chronic lower back pain (August 9, 2005 5:24:00 PM)

Hey JMA,
RD is probably the initials of the tech who shot the films.

Jeff



Alex Brenner PT MPT OCS -> Re: Chronic lower back pain (August 9, 2005 11:50:00 PM)

It is a recumbent film. RD are the initials of our radiology tech.

I agree I think that this is an old injury, there is nothing in the history to suggest that this is acute. Interestingly, when she actively extends or when you PA glide this segment she gets relief.

Here is a question for the Chiros. Would you guys manipulate this? Is this safe to manipulate in your opinion?



chiroortho -> Re: Chronic lower back pain (August 10, 2005 2:43:00 AM)

No good evidence that I'm aware of either way Alex as to whether or not manip is a good idea. I don't manip L5 when the defect is at L5, but I'll go above/below with impunity. Empirically, bilat SI manip in the prone position seems to be the best approach for me.

If her LBP didn't settle down I'd set up a retake in 6-12 months just to see if it was slipping, take just a spot lat projection.

Of all the spondys that I've seen over the years I can only recall two that went on to surgery. We're not as fragile as the radiographs make it seem.



Shill -> Re: Chronic lower back pain (August 10, 2005 3:32:00 AM)

Jason, Greg, Jeff,
Thanks for the replies on the age of the pars defect. As I read your post Jason, I had one of those "Oh yeah" moments, recalling the use of bone scans for active processes. My patient with this is a cancer survivor, (B) paresthesias to the feet/ankle, frequently changing sides, and basically not getting any better. Not a manip candidate (on which I am now trained I might add).
I sent her back to the MD.

Thanks,
Steve



chiroortho -> Re: Chronic lower back pain (August 10, 2005 4:49:00 AM)

Remember though that even w/SPECT, 'aging' a fx can be tricky. Bottom line is that a nuc med study can remain 'warm' for up to a couple of years.



UTDC -> Re: Chronic lower back pain (August 11, 2005 6:04:00 PM)

Hi Alex,
Good question. By asking if "this" could be manipulated, I assume you mean the lumbar spine, or sacroiliac joints, not the lesion per say- although with the available research on the "specificity" of manipulation, it's probably a moot point. I agree with Greg that there is really not risk of doing so (assuming a lack of hard neurological signs). I typically rule out segmental instability in such a case prior to mobilization or manipulation. The IUD on the other hand.....

Jeff



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