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Dr. Safraz Mohammed1 Dr. Robert Ravinsky2 Dr. Albert Yee3

1University of Ottawa, Neurosurgery, Ottawa Civic Hospital, Ottawa, ON.
2,3University of Toronto, Division of Orthopaedics, Department of Surgery; Holland Musculoskeletal Program and Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON.

CLINICAL TOOLS

Abstract: Degenerative conditions of the spine are a major cause of disability, and represent a large economic burden on the health care system. In this review, we have described some of the most common degenerative pathologies of the lumbar spine—low back pain, spinal stenosis, degenerative spondylolisthesis, lumbar disc herniation and cauda equina syndrome—and the diagnostic approach and immediate management from the perspective of the primary care physician. We have emphasized clinical pearls seen in these conditions and specific indications for surgical referral, as well as red flags that should prompt urgent referral for life-threatening entities, such as malignancy and infection.
Key Words: degenerative spine, surgery, lumbar disc herniation, spinal stenosis, spondylolisthesis, radiculopathy.

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1. Evaluate for hip and knee joint pathology, and vascular pathology, especially in older patients presenting with unilateral radiating leg symptoms.
2. Spine surgery is more successful in treating leg dominant pain symptoms than back dominant mechanical pain symptoms.
3. Screen every patient presenting with a lumbar spine complaint for concomitant cervical and thoracic stenosis, in particular looking for evidence of cord compression (i.e. myelopathy). Be suspicious in patients with bilateral leg symptoms.
Clinicians should ensure that a focused history and a thorough physical examination is performed to help place patients with low back pain into several key categories: (a) nonspecific low back pain (Pattern I or II), (b) back pain potentially associated with radiculopathy leg symptoms (Pattern III) or leg claudication from structural spinal stenosis (Pattern IV), or (c) back pain potentially associated with another specific spinal cause (i.e. red flags). The history should also include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain.3
Unless there are red flag symptoms or signs, routine imaging or other diagnostic tests in patients with acute nonspecific low back pain is not required.3
Diagnostic imaging and special investigations in patients with low back pain in the presence of severe or progressive neurologic deficits or when serious underlying conditions are suspected on the basis of history and physical examination.
Surgery can be helpful for patients with leg dominant symptoms (sciatica/radiculopathy, Pattern III) or leg claudication from spinal stenosis (Pattern IV). There is a limited role for surgery for back pain dominant symptoms in the absence of specific structural correlative pathology (i.e. Pattern I or II).3
Approximately 15% of patients with lumbar spinal stenosis will have concurrent cervical or thoracic canal stenosis. One must screen for the presence of upper motor neuron signs and symptoms. Degenerative lumbar stenosis always presents without upper motor findings but may occasionally have focal root compression signs.
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