Course Syllabus

Lecture Series; “Lumbar Spine A-Z”
Donald Steven Corenman, M.D., D.C.

Proposed Presentation Dates- One weekend seminar every 4 months around the country

CME is expected to accompany each seminar

This is a 12 hour lecture and video weekend lecture course designed to educate the practitioner in the diagnosis and treatment of lumbar spine disorders divided into two 6 hour days

Course Objectives:

By the end of the course, participants should be able to:

  1. Understand the anatomy, biomechanics, pathology, degenerative and traumatic injuries that occur in the lumbar spine
  2. Develop the ability to take a thorough, probing and accurate history
  3. Understand how to perform a meticulous, reproducible physical examination using videos of actual patients with pathological conditions videoed during the examination
  4. Develop the knowledge of what imaging studies are appropriate and how to order these studies
  5. Develop skills to interpret these imaging studies such as X-rays, MRIs, CT scans (with or without myelogram) and bone scans
  6. Apply analytical skills to evaluate all collected information and develop a differential diagnosis.
  7. Understand the foundations for rehabilitation therapy and use of manipulation
  8. Develop the ability to recognize spinal trauma and understand conservative and surgical management
  9. Understand the benefits and pitfalls of neurological consultations with EMG and NCV testing
  10. Understand adolescent idiopathic scoliosis and how to manage this disorder
  11. Understand adolescent lower back disorders and how to manage these disorders
  12. Understand the role of diagnostic and therapeutic injections in treatment of spinal disorders
  13. Understand the indications for surgical intervention and what surgeries are appropriate
  14. Understand how to communicate and relate findings to other practitioners and understand the different specialties that are involved in spine care

Course Reading

The textbook “The Clinician’s Guidebook to Lumbar Spine Disorders” (Author House 2011, Donald S. Corenman, M.D., D.C.) will be the source material and every participant will be given this text prior to the course.

Course Outline

Introduction

Anatomy of the Lumbar Spine and Pathophysiology of the Disc and Nerves

  • Osseous anatomy

  • Ligamentous anatomy

  • Discal anatomy

  • Facet anatomy

  • Cauda Equina anatomy

  • Mechanics of flexion/extension-effects on the disc, canal, facets and foramen

  • Muscles of the lumbar spine

  • Pelvic muscle control affecting lumbar spine

  • Discal anatomy/annular construction

  • Annular tears/nociceptors

  • Autonomic nervous system

  • Nerve cell anatomy/physiology

  • Reflex arc

  • Pain

Sources of Lower Back Pain and Leg Pain

Back pain generators

  • Annular tear

  • Degenerative disc disease

  • Isolated disc resorption

  • Facet disease

  • Central spinal stenosis

  • Hyperkyphosis thoracic spine-lumbar facet syndrome

  • Degenerative spondylolisthesis

  • Isthmic spondylolisthesis

  • Flat back disorders

  • Degenerative scoliosis

Sacroiliac, buttocks and leg pain generators

  • Herniated disc/posterolateral and far lateral

  • Foraminal stenosis/collapse

  • Lateral recess stenosis

  • Spinal stenosis

  • Sacroiliac joint dysfunction

  • Piriformis syndrome

  • Cauda Equina Syndrome

  • Myelopathy

  • Hip joint pathology

  • Insertional tendinosis/greater trochanteric bursitis

  • Peripheral nerve entrapment

Taking an Appropriate History

  • What to look for

  • How to ask the appropriate questions

  • History of symptoms

    • Onset
    • Traumatic vs non-traumatic
    • Time of day (night pain)
    • VAS
    • Weaknesses noted
    • Balance and bowel/bladder
    • Activities that aggravate and resolve
    • Activities modified or terminated
    • Sports activities modified or terminated

  • Prior treatments

  • Prior consultations

  • Prior imaging

  • Prior diagnostic blocks

  • Prior surgeries

  • Using the information in a differential diagnosis

Gait Analysis

  • Mechanism of walking

  • Muscles used in gait

  • How neurological muscle weakness will manifest in gait disorders

Physical Examination

  • What to look for

  • Initial contact (taking the history)

  • Chair sitting postures

  • Rising out of chair

  • Gait analysis (abnormals due to myelopathy, multiple sclerosis and radiculopathy)

  • Trendelenberg gait

  • Standing/walking muscle stress/fatigue testing

  • Walking maneuvers/balance testing

  • Plumb line/scoliosis/kyphosis testing

  • Flat back syndrome differential testing

  • Flexion/Extension testing

  • Assessing lumbo-pelvic rhythm

  • Phalen’s maneuver

  • Inspection of the legs

    • Fasciculations
    • Edema
    • Complex Regional Pain Syndrome (CRPS)/ (RSD)
    • Vascular signs
    • Skin signs (shingles, target lesions, venous insufficiency)
    • Capillary refill
    • Arterial doppler

  • Muscle testing/circumferential measures

  • Hip tests

  • Dermatomal testing

  • Deep Tendon Reflexes (DTR)

  • Long tract signs (hyperreflexia/clonus/Hoffman’s signs)

  • Proprioceptive testing/myelopathy

  • Lower extremity peripheral nerve entrapment testing

  • Supine provocative testing

  • Cranial nerve testing

  • Prone provocative testing

  • Palpation

  • Waddell signs

  • Putting it all together

X-ray Imaging Interpretation

  • What various X-ray images can convey

  • Normal variants

  • Degenerative disc disease/isolated disc resorption

  • Instability

  • Alignment issues

  • Slips (anterio/retrolisthesis/rotary listhesis)

  • Scoliosis

  • Foraminal stenosis/collapse

  • Bartolotti’s syndrome

  • Mach lines

  • Infection

  • Soft tissue information

MRI and CT (myelogram) Interpretation

MRI

  • MRI excitation/relaxation sequences and how to use them

  • T1, T2 and STIR images

  • Comparing axial, sagittal and coronal images

  • Degenerative disc disease/annular tears

  • Disc “bulging”

  • Disc herniation (posterolateral vs far lateral)

  • Degenerative facets

  • Degenerative spondylolisthesis

  • Isthmic spondylolisthesis

  • Instability

  • Lateral recess stenosis

  • Foraminal stenosis/collapse

  • Scoliosis

  • Stress fractures

  • Transitional vertebra

  • New vs. old fractures

  • Infections

  • Tumors and neoplasms

CT scan (with and without myelogram)

  • Image interpretation

  • Facet disease

  • Disc disease

  • Fractures

  • Degenerative vs. isthmic spondylolisthesis

  • Myelogram interpretation

  • Fusion status/screw placement

Rheumatological and Neurological Diseases

  • Rheumatoid Arthritis

  • Seronegative spondyloarthopathies

    • Ankylosing Spondylitis
    • Reiter’s Syndrome
    • Enteric Spondyloarthopathies
    • Psoriatic Arthropathies

  • DISH

  • Fibromyalgia

  • Neurological Disorders

    • Parkinson’s Disease
    • Multiple Sclerosis
    • Charcot Marie Tooth Disease
    • Peripheral Neuropathies
    • Entrapment Neuropathies
    • Amyotrophic Lateral Sclerosis
    • Guillian Barre syndrome
    • Herpes Zoster
    • Lyme disease
    • Myelopathy

Infections and Cancer

Adolescent Lower Back Pain

  • Adolescent anatomy/growth plates

  • Degenerative disc disease/annular tears

  • Adolescent disc dysplasia

  • Scheuermann’s thoracic/thoracolumbar

  • Scheuermann’s thoracic/thoracolumbar

  • Scoliosis (AIS)

  • Stress fractures (pars,pedicle,facet)/spondylolysis

  • Facet disorders

  • Alignment issues (postural roundback deformity)

  • Myofascial pain syndromes

  • Tumors and infections (osteoid osteoma, discitis)

Recognition and Conservative Treatment of Adolescent Idiopathic Scoliosis (AIS)

  • Natural history of AIS/untreated curves-why do we treat?

  • Growth remaining (apophyses, Risser sign, triradiate cartilage, secondary sex characteristics)

  • Physical Examination (plumb line, scoliometer)

  • X-ray studies (Cobb measurements- how to take appropriate X-rays)

  • Indications for bracing

  • Successful and unsuccessful treatment

  • Indications for surgery

Thoracolumbar Fractures and Dislocations

  • Normal alignment/Mechanics of fractures

  • Symptoms of fractures

  • Three column theory of stability

  • Fracture stability

  • Neurological involvement

  • Interpretation of imaging studies

  • Compression fractures

  • Burst fractures

  • Chance fractures

  • Posterior element fractures

  • Bracing options/fracture management

  • Surgical indications

Consultations, what good are they?

  • Neurologists and EMG/NCV

  • Endocrinologists

  • Rheumatologists

  • Physical Medicine physicians

  • Orthopedists

  • Neurosurgeons

  • Interventionists

Diagnostic and Therapeutic Injections

  • Diagnostic vs. therapeutic vs. provocative injections

  • Trigger point/motor point blocks

  • Epidural steroid injections

  • Selective nerve root blocks (and TFESI)

  • Facet blocks

  • Pars blocks

  • Sacroiliac blocks

  • Discograms

  • Radiofrequency ablations (RFA)/Rhizotomy

Conservative Treatment of Lumbar Disorders

  • Biomechanics of spinal disorders

  • Core strengthening

  • Flexion vs. extension treatment

  • Impact and loading

  • Role of ergonomics (activity changes)

  • Sports biomechanics

  • Mechanics of manipulation

  • Role of braces/supports

Surgical Interventions

  • Surgical expectations

  • What indications for which surgery

  • General decompressive surgeries

    • Microdiscectomy
    • Endoscopic discectomy
    • Far lateral discectomy
    • Lateral recess decompression
    • Central laminotomy
    • Central laminectomy
    • Foraminotomy

  • Fusion

    • PLF posterolateral fusion
    • ALIF anterior lumbar interbody fusion
    • PLIF posterior lumbar interbody fusion
    • TLIF transforaminal lumbar interbody fusion
    • Scoliosis surgery
    • Sacroiliac fusion

  • Artificial disc replacements (anterior approach complications)

  • Interspinous devices

  • Spinal cord stimulators/percutaneous stimulators

  • Implantable pain pumps

How to pick referral practitioners and how to communicate/How to develop a referral practice

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