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Spinal Disorders > 4 Disc Derangement > Flashcards

4 Disc Derangement Flashcards

1
Q

What 3 thingscan happen to disc?

A
  1. Degeneration — common with age, symmetrical bulge, asymptomatic
  2. Derangement — common cause of LBP, sometimes symmetrical bulge
  3. Herniation — uncommon, common cause of radicular pain, asymmetrical bulge
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2
Q

Pathoanatomical Dx, where is the pain coming from if there is lumbar pain?

If its pelvic pain?

A 
Disc 40%
Facet 5-60%
Sprain
Strain
Fracture

Pelvic:

  • SI joint
  • Hip
  • Pubic symphysis
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3
Q

Where do tears occur on the disc and what does this mean for pain sx?

A

Inner laminae of annular fibers. Tearing is more common in the posterior disc because of daily flexion loads.

Healthy discs only have pain receptors in outer 1/3 so tears do not cause pain. UNLESS there was a past injury, then pain fibers can grow to the inner rings.

Bottom line: predicting which deranged discs are causing pain is difficult.

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4
Q

In internal derangement, what will the nucleus pulposis do?

A

Migrate into fissures usually posterior direction

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5
Q

Forward flexion to the left causes herniation in what direction?

A

Posterior and to the right

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6
Q

History for a disc derangement… how does the pain present?

A

Deep, achy
Poorly localized, usually midline/bilateral and paraspinous
Constant or intermittent
Various degrees of severity
ACUTE: sx can be severe, sharp and stabbing with sudden movements, aggravated by any movement of lumbar spine

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7
Q

History for a disc derangement… what is the onset?

A

Trauma e.g. heavy lifting

Insidious due to repetitive microtrauma

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8
Q

History for a disc derangement… what aggravates?

A
  • Sitting intolerance is 1˚ complaint (though some patients get relief) and sitting may aggravate LBP rapidly
  • Worse when they first get up with antalgic posture at first
  • Pain increases when standing up from seated, trouble standing up at first
  • Dejerine’s triad
  • Pattern of flexion load sensitivity (UNLESS annular tears are anterior (uncommon) in which case the pt will have extension load sensitivity)
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9
Q

What is Dejerine’s triad?

A

Straining with bowel movement, coughing and/or sneezing

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10
Q

History for a disc derangement… referred pain?

A
  • refer unilateral or bilaterally to buttock or lower extremity (no lower than knee)
  • back pain is more intense than extremity referral
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11
Q

Can disc derangement refer to lower leg?

A

Yes, uncommon though.

Of 25 patients, 3 referred to lower leg

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12
Q

Can you distinguish facet and disc referral patterns from one another?

A

No, the referral patterns overlap too much to distinguish

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13
Q

What is the key clinical predictor of discogenic pain?

A

Pain centralization of sx during physical examination

It’s the ONLY exam finding supported by clinical evidence based on 3 studies

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14
Q

What is pain centralization?

A

Territory of pain is immediately reduced, shrinking out of leg back toward center of spine

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15
Q

How do you induce centralization?

A

Repetitive (10x) or sustained (>30 seconds) end range loading of lumbar spine both standing and non-weight bearing

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16
Q

What are the 4 key points of inducing centralization?

A
  1. Explore multiple directions
  2. Extension is the direction 60% of the time
  3. Loads may be done actively by pt or with overpressure from doc
  4. If centralization does not occur, sometimes directional preference is found because intensity of sx decrease or AROM improves
17
Q

How do you know if you found deranged disc? (3)

A

Pain centralizes
Distal symptoms decrease in intensity
AROM improves

18
Q

What are 4 physical examination findings that might favor a lumbar disc derangement over facet syndrome?

A
  1. Centralization of pain from repetitive, sustained end range loading
  2. (+) Valsalva
    3) flexion load sensitivity (over extension)
    4) max tenderness is midline with palpation
19
Q

What physical findings will you find with disc derangement… in observing their posture?

A

Flexion antalgia
Extension antalgia
Lateral pelvic shift**

Correction of lateral shift is early Tx goal

20
Q

What physical findings will you find with disc derangement?
Neuro findings?
Palpation findings?

A
  • AROM is painful, reduced more in flexion than extension (UNLESS It’s anterior disc derangement, then the pattern is reversed)
  • Minor’s sign
  • increased intradiscal pressure, so Valsalva may induce back pain

Neuro:

  • Unremarkable with normal SMR findings
  • negative tension tests
  • tight hamstrings create posterior tilt and may aggravate disc disease

Palpation:
- Interspinal tenderness with palpation

21
Q

What are procedures that compress the spine?

A
  • active double leg raise
  • 4 quadrants test
  • Muscle testing hip flexors (contraction of iliopsoas against resistance compresses the spine)
22
Q

2012 PT guideline reported that based on current evidence and panel’s expert opinion, disc derangement can be made with “reasonable level of certainty” when pt presents with the following clinical findings (3 positives +2 negatives):

A
  • LBP commonly associated with referred buttock, thigh, or leg pain that worsens with flexion activities and sitting
  • LB and LE pain that can be centralized and diminished with positioning, manual procedures, repeated movements
  • lateral trunk shifts, reduced lumbar lordosis, limited lumbar extension mobility and movement and coordination impairments are commonly present

Also

  • Nerve tension tests, and SMR testing are unremarkable
  • SI provocation tests do not provoke pts CC
23
Q

What ancillary studies might you use with suspected disc derangement?

What might you see on MRI?

A

Imagine NOT indicated unless there is consideration of aggressive Tx (surgical fusion)

Discography is gold standard
Radiographs
Dynamic views (flexion-extension)
CT
MRI — high intensity zone (HIZ)
24
Q

A positive Discography test for disc derangement must:

A

Reproduce pt’s characteristic pain and the dye demonstrate internal derangement

25
Q

How do you DDX lumbar discogenic from facet pain — which one shows pain centralization? Flexion/extension load sensitivity? Sitting aggravation? Valsalva/Dejerine’s Triad? Tenderness with palpation?

A

Disc derangement has pain centralization WITH SUSTAINED/REPETITIVE EXTENSION.
Facets = no pain centralization.

Derangement =PATTERN of flexion load sensitivity.
Facets = pattern of extension load sensitivity especially local pain with Kemp’s

Derangement = worse with sitting
Facets = may improve with sitting

Derangement = (+) Valsalva, Dejerine’s Triad

Derangement = tenderness midline
Facets = tenderness over facet
26
Q

How do you manage suspected disc injury?

A

Active rest: bed rest should be limited to <2 days

CMT: in acute phases, manipulation into pain centralizing or directional preference (e.g. extension) may be safest
- Flexion-distraction

STM: stretch hamstrings

Exercise: directional preference (AKA McKenzie) exercises can be given on first visit
- ACUTE phase 10 reps every hour

Behavioral Modification: limit flexion loads and in the morning (2 hours) because disc is fully hydrated

  • reduce sitting time
  • break up sitting with stretching every 20-30 minutes
  • hip hinging, neutral pelvis, abdominal bracing and explain how to get in and out of a chair, on and off the table, bend to pick up objects from floor
  • teach lifestyle activities (how to get out of car, how to wash dishes, how to shower without bending over)
  • core stabilization exercises are NOT for acute patients
27
Q

How to avoid flexion (3 methods to teach to patients)

A
  1. Stand at sink and place one foot on a shelf
  2. Swing both legs out of the car so both feet hit the ground
  3. Keep soap at high level and hip hinge to wash feet or shave legs
28
Q

If conservative therapy fails, how do you manage patient pain? And what is the timeline for that?

A

3-6 months of conservative therapy

Epidural injections before surgery or invasive disc procedures

Spinal fusion is common, but question as to overall effectiveness

Intradiscal electrothermal therapy (IDET) and percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) are options but remain controversial with little evidence to support their use

Spinal Disorders (5 decks)

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