MSK-15 · Spine: Stenosis, Spondylolisthesis, and Facet-Mediated Pain

Spine: Stenosis, Spondylolisthesis, and Facet-Mediated Pain. Part of the Musculoskeletal series of the Reflex PM&R Board Review podcast. Audio corrections: (1) In the audio: The stark reality is that it does not reliably respond to conservative management. — Correct: Conservative care does not reverse established myelopathy, but that is not the same as never observing. Mild, non-progressive myelopathy (mJOA 15 or higher with a stable examination) may be watched with rehabilitation and neurologic re-examination every 6 to 12 months; moderate, severe or progressing disease goes to decompression. (2) In the audio: In fact, 85 to 95 percent of all spondylolysis cases occur precisely at L5. — Correct: That figure comes from the plain-film era. CT and MRI series put roughly two thirds of pars defects at L5, with L4 accounting for a further 20 to 30 percent. Teach L5-predominant with L4 a real second. (3) In the audio: it strongly correlates with active discogenic low back pain — Correct: Modic type 1 is not established as more painful than type 2. The best systematic review found no consistent difference between the types, the overall association with axial pain is modest, and basivertebral nerve ablation targets types 1 and 2 together. (4) In the audio: Mild curves, defined as under 60 to 70 degrees, — Correct: Observation with exercise applies under about 50 degrees. A 55 to 70 degree curve in a skeletally immature patient is brace territory, and 60 to 70 degrees overlaps the episode's own 50 to 75 degree bracing band. (5) In the audio: You send the patient to surgery for a slip of grade 3 or higher, — Correct: Grade alone is not a surgical indication. An asymptomatic high-grade slip is managed nonoperatively with activity modification and surveillance; surgery is for documented progression, neurologic deficit, dynamic instability or refractory pain. (6) In the audio: but each individual joint receives medial branch fibers from two entirely separate spinal levels — Correct: That is the lumbar rule. Cervical facets take the medial branches of their own two numbers (C5-C6 from C5 and C6), and the C2-C3 joint is supplied by the third occipital nerve alone. (7) In the audio: the critical diagnostic standard for developmental cervical stenosis is a Torg-Pavlov ratio of under 0.8 — Correct: The 0.8 cutoff is a sensitive screen with a positive predictive value well under 1 percent in athletes, because a large vertebral body drives the ratio down without true canal narrowing. It must never by itself disqualify an asymptomatic athlete from contact sport; get MRI canal and cord measurements instead. (8) In the audio: The formal definition of lumbar instability is a forward translation greater than 5 millimeters, or an angular change greater than 15 degrees between the flexed and extended radiographic views. — Correct: The lumbar criteria are translation greater than 4.5 mm or 15 percent of the vertebral body width, and a level-specific sagittal rotation: greater than 15 degrees at L1-2 through L3-4, greater than 20 degrees at L4-5, and greater than 25 degrees at L5-S1. One 15-degree cutoff for the whole lumbar spine under-calls instability at the two lowest segments. The written chapter is correct. Full correction register: https://www.reflexpmr.com/errata. The full companion chapter and a linked board-style Q-bank set for this topic are at https://www.reflexpmr.com/read/MSK-15.