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OPP II > 1-20 Low Back Pain & Herniated Nucleus Pulposus > Flashcards

1-20 Low Back Pain & Herniated Nucleus Pulposus Flashcards

1
Q

What is the lifetime prevalence of LBP?

A

70%

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2
Q

What is the cost of LBP, in terms of physician visits and surgical procedures?

A

2nd most common reason for physician visits

3rd most common reason for surgical procedures

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3
Q

What is the total cost ($) of LBP in the US?

A

> $100 billion

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4
Q

What are the quality of life costs of LBP?

A

72% gave up on exercising or sport

46% gave up on sex

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5
Q

What should be first taken into account when creating a DDx for LBP?

A

Localized or diffuse

If local, is it mechanical?

If mechanical, is there radiation below the knee?

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6
Q

What 6 things should be considered for a DDx for localized LBP, mechanical, without radiation below the knee?

A

Non-specific muscular and/or ligamentous injury

Somatic dysfunction

Degenerative disc disease

Degenerative joint disease

Spondylolithesis

Fracture/spondylolysis

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7
Q

What 3 things should be considered for a DDx for localized LBP, mechanical, WITH radiation below the knee?

A

Cauda Equina Syndrome

Radiculopathy

Spinal stenosis

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8
Q

What should be considered for localized LBP without a mechanical cause?

A

Infection

  • osteomyelitis
  • discitis

Neoplasm

  • primary (osteosarcoma, osteoidosteoma)
  • metastatic (breast, lung, thyroid, kidney, prostate)
  • multiple myeloma

Inflammation

  • spondyloarthropathy
  • Rheumatoid arthritis
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9
Q

What should be considered for a referred LBP?

A

GI Disease

  • IBD
  • Diverticulitis
  • Pancreatitis

Renal Disease

  • Nephrolithiasis
  • Pyelonephritis

Gynecological problems

  • Endometriosis
  • Menstrual cramps

Vascular
- Abdominal aortic aneurysm

Psychological

  • Somatoform disorder
  • Malingering
  • Central sensitization/chronic pain syndrome
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10
Q

What can relief of LBP with complete immobility tell you?

A

It might be due to:

  • acute infection
  • compression - suspect metabolic bone disease
  • pathological fracture - suspect tumor or infiltrative disease
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11
Q

What can aggravation of LBP with prolonged sitting or leaning forward tell you?

A

Might be due to:

- herniated disc

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12
Q

What can aggravation of LBP with prolonged standing and extension tell you?

A

Might be due to:
- spinal stenosis
“shopping cart sign”

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13
Q

What can lack of relief of LBP in any position tell you?

A

Might be:

- psychogenic pain

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14
Q

What are some symptoms of psychogenic LBP?

A

Not well localized, follows no pattern, constant, and patients cannot describe alleviating or aggravating factors.

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15
Q

What is shopping cart sign?

A

Shopping cart sign: pain relieved when leaning forward onto a shopping cart; forward bending causes spinal canal and foramina to open which relieves pressure

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16
Q

What are 2 clues that you need to consider with radiating pain?

A

Radiating pain with extension
- stenosis

Radiating pain at rest
- Disc herniation

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17
Q

What should be considered with stiffness and pain upon walking?

A

Inflammatory arthropathies

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18
Q

What does intense night time pain indicate?

A

bone tumors

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19
Q

What are 6 red flags that should be considered before treating LBP?

A

Bowel or bladder dysfunction
Saddle anesthesia
B/L weakness or numbness in legs
Acute neuro deficits in patients with cancer
- BLT with a Kosher Pickle
Progressive or severe neuro deficit
LBP along with fever in a patient who uses IV drugs

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20
Q

Why should you consider red flags before treatment?

A
  • I would not treat these patients until these sx have been immediately investigated. Law suit territory.
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21
Q

What is a yellow flag? How would you proceed?

A

Positive straight leg raise test

I may treat GENTLY during the first visit that they exhibit these findings, but I wouldn’t have them back for another treatment until this is investigated.

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22
Q

What is a straight leg raise test?

A

Straight leg raising is done with the patient supine. The examiner raises the patient’s extended leg with the ankle dorsiflexed, being careful that the patient is not actively “helping” in lifting the leg. The test is considered positive when the sciatica is reproduced between 10 and 60 degrees of elevation.



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23
Q

What is the crossed straight leg test?

A

The crossed straight leg raising test refers to elevation of the unaffected leg. The test is positive when lifting the unaffected leg reproduces the sciatica in the affected leg.

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24
Q

What is the seated straight leg test?

A

The seated straight leg test is done while the patient is in the seated position and the lower leg is slowly extended until the leg is flexed at the hip to 90 degrees. If sciatica is present, the pain will be reproduced as the leg is extended.



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25
What does a positive straight leg test have limited sensitivity for?
has limited sensitivity and specificity for herniated disc (64 and 57 percent respectively)
26
What is the crossed straight leg test sensitive for? Specific?
[53]. The crossed straight leg test is less sensitive for herniated disks, but is 90 percent specific.”
27
Case 1: A 54 yo male presents with low back pain x 1 month. He describes the pain as a dull ache that is worse at the end of the day. He works as a therapist and sits at a desk for most of the day. What else do we want to know?
No radiation No weakness or numbness No change in bowel or bladder function PMH noncontributory
28
What should be considered in cases of LBP with shoulder pain?
Latissimus dorsi Originates in the thoracolumbar fascia, iliac crest and spinous processes of lower 6 thoracic vertebrae and inserts on the intertubercular groove of the humerus Functionally connects the lumbar, thoracic, and pelvic regions to the upper extremity
29
What is the origin of the quadratus lumborum?
Origin is the iliolumbar ligament and iliac crest; inserts on the tips of the L1-4 transverse processes and the anterior surface of the 12th rib
30
What is the QL considered a part of, functionally?
Functionally considered a posterior inferior extension of the abdominal diaphragm
31
What is the iliopsoas attached to?
Are attached to the vertebral bodies and the anterior surfaces of the transverse processes of the lumbar spine and insert on the lesser trocanter of the femur
32
Why is the iliopsoas problematic?
The “hidden prankster” serves many important functions, often causes pain, and is relatively inaccessible
33
What is an important joint that can contribute to LBP?
Sacro-iliac joint
34
Case 2: A 61 yo male presents with low back pain x 2 weeks. He describes the pain as achy and burning. He works as a home health nurse where he is standing or walking for most of the day, which he says is helpful because the pain worsens with prolonged sitting – especially during his 45 minute commute. What else do we want to know?
``` Pain radiates down his right leg into his calf Pain radiates at rest No weakness or numbness No change in bowel or bladder function PMH is noncontributory ```
35
What compromises the intervertebral foramina and disc?
``` Arthritis Ligament hypertrophy Disc degeneration Muscle imbalance Inherent tissue qualities Somatic dysfunction ```
36
What are 8 radiculopathy etiologies?
``` Herniated nucleus pulposus from a ruptured disc pressing on nerve root or cord Bulging disc Disc degeneration Bone tumor Exostoses Spinal stenosis Infection Can often be precipitated or aggravated by somatic dysfunction especially if a chronic process has already compromised the foramen or canal ```
37
What are some anatomical features of the intervertebral disc?
Mostly water Few pain fibers Compression pressure balanced by hydrostatic forces Annulus Fibrosus and Nucleus pulposus Too much pressure can expel NP from the disc
38
What are the 4 stages of disc herniation?
Degeneration Prolapse Extrusion Sequestration The disc may be protruded (with the annulus intact), extruded (through the annulus but contained by the posterior longitudinal ligament), or sequestered (free within the spinal canal)
39
Are disc herniations more common posteriorly or anteriorly?
Posteriorly The anterior longitudinal ligament is much thicker and stronger than its posterior counterpart.
40
Where are most disc herniations on the posterior spine?
Disc herniations are more common paracentrally or parasagitally
41
What prevents central herniation on the posterior spine?
The posterior longitudinal ligament prevents central herniation
42
What is the most common region for disc herniation?
Discs most commonly herniate in lumbar regions | - This region undergoes more motion stress
43
What are the most commonly herniated discs?
Most commonly herniated discs are L5-S1 and L4-5 - These segments undergo the most motion and experience functional and postural stress - The posterior longitudinal ligament is more narrow at these levels L5-S1 is most common, L4-5 is the second most common
44
What limits movement in the thoracic region of the back?
Even though the lumbar facets are in the sagittal plane and thoracic facets are in the coronal plane and would allow more motion, the rib cage hinders motion in the thoracic region.
45
What nerve root is most commonly affected by disc herniations? What is protective of nerve roots?
Disc herniation most commonly affects the the nerve root below Pedicles of the lumbar vertebrae protect a nerve from being injured by the disc at its own level
46
Where are the pedicles of a vertebra located in regards to the nerve? How is this significant for symptomatic herniated discs?
The pedicles of a lumbar vertebra are located on the superolateral 1/3 of the lumbar vertebral body, so a lumbar nerve winds around a pedicle and passes through its foramen, before it passes over the disc of that vertebral unit. Remember that a bulging disc does not necessarily produce radiculopathy unless it is significant.
47
What are some clinical features of a herniated L4-5 disc?
Pain over sacro-iliac joint, hip, lateral thigh and leg Numbness in lateral leg, first 3 toes Weakness with dorsiflexion of great toe and foot, difficulty walking on heels, foot drop may occur minor atrophy reflexes - changes uncommon in knee and ankle jerks, but internal hamstring reflex diminished or absent
48
What are some clinical features of a herniated L5-S1 disc?
Pain over sacroiliac joint, hip, posterolateral thigh and leg to heel Numbness on back of calf, lateral heel, foot to toe Weakness of plantar flexion of foot and great toe may be affected, difficulty walking on toes Atrophy of gastrocs and soleus Reflexes - ankle jerk diminished or absent
49
What are some risk factors for HNP?
Occupational lifting - Nurse, EMT, Construction worker, Firefighter, etc. Bending or lifting precipitated the incident Previous history of low back pain Age Tobacco use Ethanol use
50
What are some symptoms of HNP that differentiate it from SD?
HNP: Produces dermatomal pattern of symptom distribution Hypertonic paraspinal muscles and hypotonic lower limb muscles and possible calf atrophy SD: Produces glove-like distribution of symptoms Hypertonic paraspinal and lower extremity muscles due to increased sympathetics
51
What are some similarities between HNP and SD?
Both can be associated with major or minor trauma Both can produce numbness, weakness, and tingling
52
What are some major symptoms of HNP?
LBP that radiates down the back of the leg to the calf or foot Symptoms improve with rest
53
What is a medical emergency with HNP?
loss of bowel and bladder control = surgical emergency!!
54
What are some major symptoms associated with LBP with SD?
LBP that radiates: - Down buttocks and anterior and posterior thigh - Rarely below the knee - Groin pain due to irritation of the ilioinguinal and iliohypogastric nerves from tension on iliolumbar ligament - Psoas tightness can cause radiation pain to anterior thigh due to irritation of the lumbar plexus Symptoms improve with activity
55
What is a treatment plan for HNP?
``` Rest (no confinement) - continue exercise or PT as tolerated Continue anti-inflammatory treatment Analgesics Muscle relaxants OMT ```
56
What is involved in discogenic pain with HNP?
Fissure in annulus fibrosus Sinuvertebral nerve Nociceptors annulus fibrosus DRG Nucleus pulposus - phospholipase A2 - Prostaglandins - NO - metalloproteinases
57
What is involved in the inflammatory side of HNP?
Neovascularization of disc | Inflammatory cell inflitrate
58
How does inflammation help create discogenic pain?
Chemicals may reach nociceptors via adjustment to lower threshold for firing. Pain cause by mechanical forces superimposed by chemically activated nociceptors.
59
How does inflammation help create HNP pain?
Nerve root-dura interface may be involved by inflammatory process. Chemical factors and compression both contribute to lumbar pain.
60
What is the role of acute SD on radiculopathy?
If intervertebral foramen was already compromised by a chronic process, an acute SD can precipitate or aggravate symptoms
61
What can cause a decrease in the space in the vertebral foramen?
``` Normally the foramen is 2-3x larger than the nerves, but this space may be decreased by: arthritis or spurs extrusion of the NP tissue congestion or edema inflammation perineural edema SD ```
62
What is the role of chronic SD on radiculopathy?
Chronic SD can alter the mechanical forces on the disc - Type I SD - Long paraspinals - Type II SD - Short paraspinals
63
What is the pattern induced by type I SD?
Type I Group curves involving several vertebrae. Induced by long restrictor muscles Usually compensatory. Sidebending and rotation are to OPPOSITE directions The sidebending component is primary NEUTRAL posture Motion is directed by the vertebral bodies and their discs
64
What is the pattern induced by type II SD?
Type II Involve single segments, (two vertebrae/one joint) Induced by short restrictors Usually traumatic or non-physiological Sidebending and rotation to SAME side Found in non-neutral posture (flexion or extension) Flexion or extension engages the facets so motion limited to single segments
65
What should be considered when thinking about the role of the lumbar spine on the whole body as a unit?
Role of lumbar spine on the whole body as a unit | - Musculoskeletal, respiratory, circulatory consequences
66
What is the musculoskeletal model for the lumbar region?
Occupies ½ - 2/3 of the posterior skeletal and myofascial wall of the abdomen Directly linked to the thoracic and pelvic regions Influences head and neck, upper and lower limbs, and the viscera via functional anatomic connections
67
What is the respiratory/circulatory model for the lumbar region?
Located between 2 greater areas of stability, it therefore is associated with two junctional areas, the thoracolumbar junction and the lumbosacral junction These junctional areas are key for lymphatic and venous drainage and return
68
What is the attachment of the abdominal diaphragm?
Attaches from the bodies of L1-3 to the lower 6 ribs and xiphoid process
69
What SDs can affect the abdominal diaphragm?
SD of L1-3 can be associated with a flattened, ineffective diaphragm
70
What problems can a flattened abdominal diaphragm cause?
A flattened diaphragm is unable to develop efficient, appropriate pressure gradients between the thorax and abdomen, resulting in decreased lymphatic flow and venous return (Batson’s Plexus) and increased abdominal and pelvic congestion
71
What are the OMT treatment goals?
Address SD which may aggravate nerve root impingement locally Address SD which contribute to a functionally imbalanced lumbar spine via the tensegrity/kinetic chain approach Treat SD associated with postural imbalance Reduce viscerosomatic reflexes Reduce sympathetic tone Ensure optimal diaphragm position to improve lymphatic and venous drainage
72
What areas do we treat when evaluating LBP with OMT?
``` Lumbar spine Sacrum Pelvis Thoracic spine Ribs Diaphragm Cranial system Extremities ```
73
What should the OMT treatment plan involve with an acute case of LBP?
Indirect techniques are generally better tolerated – counterstrain, FPR, Still Technique, BLT, myofascial release, cranial HVLA and MET are relatively contraindicated in the acute case
74
What should the OMT treatment plan involve with a subacute/chronic case of LBP?
Indirect techniques are still fine but can incorporate direct as well – muscle energy, articulatory, HVLA Any technique that aggravates the symptoms is contraindicated
75
When is surgery an option with LBP?
Neurologic deficit Continued pain combined with 2 or all 3 of the following: paresthesia, reflex changes, and muscle atrophy Increase in intensity of symptoms despite conservative care When there is a clear picture of the etiology – DON’T CHASE PAIN

OPP II (2 decks)

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